BH  I 


COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STArjDARD 


HX64085376 
QM531  .R19  1913  Landmarks  and  surfac 

RECAP 


i 


Columbia  (Hnit)et^ftj) 

mtljeCtlpofiUmgork 

THE  LIBRARIES 


Mtbital  Hitirarp 


Digitized  by  the  Internet  Arcinive 

in  2010  witii  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/landmarkssurfaceOOrawl 


*^'- 


LANDMARKS  AND   SURFACE  MARKINGS 
OF  THE  HUMAN   BODY 


V 


A 


Verj-eoral  border 
ofScdpuia  '~- 

liifrdspindtus--. 


I'/Dorsdl  ^ 


?  srerno- 


Hamstrings  -^ 


Gastrocnemius 


ulnaris ' 


Tennnr  Fasciae  kmoris 
Gluteal  cleft 


Gluteal  Fold 


Popliteal  space 


-Ilio -tibial  band 
Biceps  Femoris 


External  saphenous 
vein 


-External  saphenous  vein 
,'Fibula 


I'endo  Actiilles 


LANDMARKS  AND 

SURFACE    MARKINGS   OF 

THE  HUMAN   BODY 


BY 

L.  BATHE   R^AWLING 

M.B.,  B.C.  (Cant.),  F.R.C.S.  (Eng.) 

Surgeon  with  charge  of  Out-Patients,  Demonstrator  of  Practical  and  Operativh 

Sui;GERy,  late    Senior   Demonstrator   of   Anatomy    at   St.    Bartiiolomew's 

Hospital  ;  late  Assistant-Slrgeon  to  the  German'  Hospital,  Dai.ston  ;  late 

Hunterian   Professor.   Royai,  College  of  Surgeons,  England,  etc. 


WITH  THIRTY-ONE  ILLUSTRATIONS 


FIFTH    EDITION 


PAUL  B.  HOEBER 

69,    EAST    59TH    STREET 

NEW  YORK 


o.  -. 


^•^ce;  ^ 


Printed  in  England,  1912 


PREFACE 
TO   THE    FIFTH    EDITION 

From  the  fact  that  the  fourth  edition  was  disposed  of 
within  one  year,  it  would  appear  to  me  obvious  that  but 
little  alteration  or  addition  is  necessitated  for  this  edition ; 
the  text  has  been  adhered  to,  but  the  illustrations  have 
been  improved. 


L.  BATHE  RAWLING. 


1 6,  Montagu  Street, 
PoRTMAN  Square,  W. 
1912 


CONTENTS 


CHAPTER  I 

PAGE 

THE  HEAD  AND   NECK  -  -  •  -  -  -         1 

CHAPTER   II 
THE  UPPER  EXTREMITY       -  -  -  •  -  -      19 

CHAPTER  III 

THE  THORAX  -  -  -  -  -  -  *      34 

CHAPTER  IV 
THE  ABDOMEN  -  -  -  -  -  -  "49 

CHAPTER  V 

THE  LOWER   EXTREMITY      -  -  •  -  -  -     70 

APPENDIX 

THE  LENGTH   OF  VARIOUS   PASSAGES,  TUBES,   ETC.  -  -  86 

THE  WEIGHT  OF  SOME  ORGANS     -               -               -  -  -  88 

THE    OSSIFICATION    AND    EPIPHYSES    OF    THE     BONES  OF  THE 

UPPER   AND   LOWER  EXTREMITIES       -               -  •  -  89 

INDEX  -  •  -  -  -  -  -  -      92 


ILLUSTRATIONS 


I  and  2.  Cranio-cerebral  Topography 
3  and  4.  The  Side  of  the  Neck 

5.  The  Front  of  the  Neck 

6.  The  Front  of  the  Arm  and  Forearm 

7.  The  Elbow  and  Back  Region 

8.  The  Elbow  Region     .... 

9.  The  Veins  of  the  Arm  and  Forearm 
10  and  II.  The  Palm  of  the  Hand 

12.  The  Back  of  the  Wrist 

13.  The  Back  of  the  Arm  and  Forearm 

14.  The  Shoulder  and  Arm 

15.  The  Heart,  Great  Vessels,  Kidney,  and  Ureter 
16  and  17.  The  Pleural  Sacs,  Lungs,  etc. 

18.  The  Abdominal  and  Thoracic  Planes 

19.  The  Alimentary  Canal  ... 

20.  The  Liver,  Anterior  Abdominal  Wall,  etc. 
21  to  24.  The  Thigh  and  Leg 

25  and  29.  The  Region  of  the  Ankle  and  Foot 


To  face  p. 


4 

I4»  15 

18 

20 

23 
24 
24 
26 
28 
30 
31 
36 
41,42 

50 
56 
62 

70,74 
77-80 


viii 


LANDMARKS   AND   SURFACE 
MARKINGS  OF  THE   HUMAN   BODY 

CHAPTER  I 
THE  HEAD  AND  NECK 

Cranio-cerebral  Topography 

Only  those  surface  markings  will  be  given  which  are  of 
practical  value,  and,  as  far  as  possible,  each  landmark  will 
be  rendered  independent  of  any  other,  as  by  such  means 
any  given  structure  can  be  rapidly  depicted  on  the  surface, 
the  important  question  of  time  and  of  space  rendering  the 
more  complicated  systems,  in  which  it  is  necessary  to  map 
out  a  network  of  intersecting  lines  in  order  to  fix  the 
position  of  any  single  structure,  of  little  surgical  value. 
It  is  necessary,  however,  to  recognize  first  certain  impor- 
tant bony  points,  etc. 

The  nasion,  situated  at  the  base  of  the  nose  at  the 
Fig.  i.,  1.      central  point  of  the  naso-frontal  suture. 

The  inion,  or  external   occipital  protuberance, 
Fig.  i.,  2.     a   projection,    variable    in    size,    which    can    be 
readily  felt  on  the  occipital  bone,  immediately 
above  the  nuchal  furrow. 

A  line  uniting  these  two  points  over  the  vertex  of  the 
skull  corresponds  in  direction  to  the  mesial  longitudinal 
fissure  of  the  brain,  to  the  upper  attached  margin  of  the 

I 


2  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

falx  cerebri,  and  to  the  stiperior  longitudinal  venous  sinus. 

This  sinus  originates  in  the  region  of  the  foramen  caecum, 

just    anterior    to    the    crista    galli,    and     broadens    out 

rapidly   as    it    passes    backwards    towards    the    internal 

occipital  protuberance,  which  lies   at   the   same   level  as 

the  previously  mentioned  external  protuberance.     It  then 

turns  sharply  to  the  right,  forming  the  right  lateral  sinus^ 

The  left  lateral  sinus  derives  its  blood  mainly  from  the 

straight  sinus,  which  receives,  at  the  anterior  margin  of  the 

tentorium   cerebelli,  the  great  vein  of   Galen,  the  main 

efferent  trunk  of  the  deep  nuclear  cerebral  veins.     The 

line  drawn  as  above  from  the  nasion  to  the  inion   also 

corresponds   in   direction   to   the   occasionally   persistent 

metopic  suture  between  the  two  halves  of  the  frontal  bone, 

and  to  the  sagittal  suture  between  the  two  parietal  bones. 

The  frontal  bone  is  separated  off  from  the  two  parietal 

bones  by  the  coronal  suture,  and  the  point  of  junction  of 

the  coronal  and  sagittal  sutures  is  known  as  the  bregma, 

the  site  of  the  foetal  anterior  fontanelle,  an  opening  which 

is  normally  closed  by  the  end  of  the  second  year.    Between 

the  parietal  and  occipital  bones  the  lambdoid  suture  lies ; 

and  at  the  junction  of  the  sagittal  and  lambdoid  sutures 

the  posterior  fontanelle  is  situated,  closed  at  or  soon  after 

birth.     The  point  of  junction  of  the  last  two 
Fig.  i.,  13.  .  ^  •* 

sutures  is  known  as  the  lambda.      This  point 

lies  about  2|  inches  above  the  inion  or  external  occipital 

protuberance.      About  i  inch  from  its  posterior  superior 

angle,  and  close  to  the  sagittal  suture,  the  parietal  bone 

is  perforated  by  a  small  foramen,  and  a  line  uniting  the 

two  foramina  crosses  the  sagittal  suture  at  a  point  known 

as  the  obelion.     The  parietal  bone  is  outwardly  bulged  at 

a   point   rather   above  its  centre,  forming:   the 
Fig.  i.,  11.  ,  .  '^ 

parietal  eminence,  especially  marked  in  the  foetal 


THE    HEAD    AND    NECK  3 

skull,  and  indicating  the  point  at  which  the  single  ossific 

nucleus  makes  its  appearance. 

Turning  now  one's  attention  to  the  lateral  aspect  of  the 

skull,  the  inferior  temporal  crest  should  be  ex- 
Fig,  i.,  6.  .  .  ^ 

amined.      This  crest  crosses  the  parietal  bone 

rather  below  the  junction  of  the  middle  and  lower  thirds, 
cutting  off  the  vault  proper  above  from  the  temporal  fossa 
below\  The  ridge  is  often  so  feebly  developed  in  this 
region  that  it  may  be  necessary  to  verify  its  position  by 
tracing  it  backwards  from  the  region  of  the  external 
angular  frontal  process,  at  which  level  the  crest  is  always 
well  marked.  The  temporal  muscle  arises  from  the  inferior 
temporal  crest  and  from  the  temporal  fossa  below,  whilst 
the  overlying  fascia,  the  temporal  fascia,  gains 
attachment  to  the  superior  temporal  crest  —  a 
feebly  developed  ridge  which  runs  above  and  parallel  to 
the  inferior  crest.  To  avoid  confusion,  it  is  perhaps 
necessary  to  add  that  the  inferior  temporal  crest  is  quite 
distinct  from  the  infratemporal  crest,  which  forms  the 
lower  margin  of  the  temporal  fossa,  and  separates  off  that 
fossa  from  the  zygomatic  fossa. 

The    external    angular  frontal  process    articulates   with 

the    frontal    process   of    the   malar   bone,    and 

the  articulation  between  the  two  processes  is 

easily  felt  at  the  upper  and  outer  border  of  the  orbital 

cavity. 

The   malar   tubercle,   a    small    prominence    to    be    felt 

alone:  the  posterior  border  of  the  frontal  pro- 
Fig   i    12. 

'      *    cess  of  the  malar  bone,  a  short  distance  below 

the  fronto-malar  suture. 

The  zygomatic  process  of  the  temporal  bone  should  be 

traced  backwards  towards  the  ear,  and  an  examination  of 

the  skull  will  show  that  this  process  divides  in  front  of  the 

I — 2 


4  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

ear  into  three  roots,  the  anterior  merging  into  the  eminentia 
articularis,  the  middle  helping  in  the  formation  of  the 
post-glenoid  process,  whilst  the  posterior  or  upper  root 
Fig.  ii., 13,14  sweeps  backwards  above  the  external  auditory 
Fig.  I.,  17.  meatus  to  become  continuous  with  the  supra- 
meatal  and  supramastoid  crests,  and  to  blend  with 
the  posterior  curved  end  of  the  temporal  crest.  The 
suprameatal  crest  is  of  special  surgical  importance,  as  it 
forms  the  upper  boundary  of  Macewen's  suprameatal 
triangle,  and  also  indicates  fairly  accurately  the  lower 
level  of  the  cerebrum  in  this  situation. 

The  lateral  sinus  describes  a  gentle  curve  from  the 
Fig.  i.,  16.  external  occipital  protuberance  to  the  upper 
Fig.  ii.,  9.  ^^^  posterior  part  of  the  base  of  the  mastoid 
process,  finally  curving  downwards  towards,  though  not 
reaching  to,  the  apex  of  that  process.  The  degree  of 
upward  curve  is  subject  to  a  good  deal  of  variation, 
and  the  sinus  frequently  presents  a  lesser  upward  con- 
vexity than  was  the  case  in  the  specimen  from  which 
the  illustration  was  taken. 

The  lower  limit  of  the  cerebrum  can,  with  sufficient 
Fig.  i.,  17,    accuracy,    be    mapped    out    in    the   following 

'•7,  17.  manner:  A  point  is  taken  in  the  median 
antero-posterior  line  about  |  inch  above  the  nasion,  and 
from  this  point  a  line  is  drawn  outwards  which  lies  about 
I  inch  above,  and  follows  the  curve  of  the  upper  border 
of  the  orbit.  This  line  is  carried  backwards  as  far  as 
the  level  of  the  external  angular  frontal  process,  then  curv- 
ing upwards  and  backwards  towards  the  Sylvian  point  (see 
next  page).  The  temporo-sphenoidal  lobe  sweeps  now 
downwards  and  forwards  towards  the  posterior  border  of 
the  malar  bone,  and  then  lies  practically  on  a  level  with 
the  upper  border  of  the  zygoma.     At  and  behind  the  ear 


FIG.  I. 

1.  The  nasion. 

2.  The  inion. 

3.  The  mid-point  between  nasion  and  inion. 

4.  The  Rolandic  fissure. 

5.  The  superior  temporal  crest. 

6.  The  inferior  temporal  crest. 

7.  The  Sylvian  point. 

8.  The  anterior  horizontal  limb  of  the  Sylvian  fissure. 

9.  The  vertical  limb  of  the  Sylvian  fissure. 

10.  The  posterior  horizontal  limb  of  the  Sylvian  fissure. 

11.  The  parietal  prominence. 

12.  The  malar  tubercle. 

13.  The  lambda. 

14.  The  first  temporo-sphenoidal  sulcus, 

15.  The  external  parieto-occipital  sulcus. 

16.  The  lateral  sinus. 

17.  17,  17.  The  level  of  the  base  of  the  cerebrum. 

18.  The  external  auditory  meatus. 

19.  19.  Reid's  base  line. 


CRANIO-CEREBRAL  TOPOGRAPHY 


I'IG.  I. 


To  face  p.  4. 


FIG.  II. 

/,  I.  Reid's  base  line. 

2.  2.  A  line  parallel  to  the  above  at  the  level  of  the  supra- 

orbital margin. 

3.  The  middle  meningeal  artery. 

4.  The  anterior  branch. 

5.  5,  5.  The  three  sites  for  trephination. 

6.  The  posterior  branch. 

7.  The  site  for  trephination. 

8.  The  point  for  trephining  to  reach  the  descending  horn 

of  the  lateral  ventricle. 

9.  The  lateral  sinus. 

10.  The  inion. 

11.  The  mastoid  process. 

12.  Macewen's  suprameatal  triangle. 
12a.  The  mastoid  antrum. 

12b.  The  facial  nerve. 

13.  The  suprameatal  and  supramastoid  crests. 

14.  14.  The  temporal  crest. 

15.  The  temporal  fossa. 

16.  The  external  angular  frontal  process. 

17.  The  tendo-oculi  attachment, 

18.  The  lachrymal  groove. 


CRANIO-CEREBRAL   TOPOGRAPHY 


FIG.    TI. 

To  follow  Fit;.  /. 


THE    HEAD   AND    NECK  5 

the  cerebrum  lies  flush  with  the  suprameatal  and  supra- 
mastoid  crests,  and  subsequently  follows  the  curve  of  the 
lateral  sinus  from  the  base  of  the  mastoid  process  to  the 
external  occipital  protuberance. 

The  lateral  sinus  is,  to  a  large  extent,  walled  in  by  the 
tentorium  cerebelli,  a  membrane  separating  the  cerebrum 
and  cerebellum  one  from  the  other.  The  sinus  curve, 
therefore,  corresponds  not  only  to  the  position  of  the  lateral 
sinus,  but  also  represents  the  outer  attachment  of  the 
tentorium  cerebelli,  and  the  interval  between  the  cerebrum 
above  and  the  cerebellum  below. 

Reid's  base  line  is  drawn  backwards  from  the  lower 
r:\rr  ;    1Q       border  of  the  orbit  to  the  middle  of  the  external 

r  ig.   I.,    !», 

IS-  auditory  meatus,  and,  when  further  produced, 

'^"  "■'  '  ■  the  line  will  be  found  to  fall  just  below  the 
level  of  the  inion,  and  to  lie  almost  entirely  below  the 
level  of  the  lateral  sinus.  This  line  is  utilized  by  some 
surgeons  in  trephining  the  skull,  distances  being  measured 
along  this  line  and  points  taken  above  or  below,  according 
to  the  seat  of  the  lesion. 

The  Sylvian  point  represents  the  site  of  divergence  of 
the  three  limbs  of  the  Sylvian  fissure.     It  lies 
i:^  inches  behind  the  external  angular  frontal 
process,   and   i^  inches  above  the  upper  border  of   the 
zygoma.      The   main    posterior   horizontal   limb   of    the 
Fig.  i.,  10,    Sylvian  fissure  passes  backwards  and  upwards 
^^-  from    the    Sylvian    point    to    a   second   point 

situated  f  inch  below  the  most  prominent  part  of  the 
parietal  bone. 

The  vertical  limb  is  directed  upwards  for  about  f  inch, 
whilst  the  anterior  horizontal  limb  passes  for- 
wards for  about  the  same  distance. 
The  Sylvian  point  corresponds  also  to  the  anterior  pole 


Fig.  i,  7. 


6  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

of  the  island  of  Reil  and  to  the  middle  cerebral  artery,  as 
that  vessel  lies  deeply  embedded  in  the  anterior  part  of 
the  Sylvian  fissure. 

To  mark  out  the  external  parieto-occipital  fissure  and  the 
Fig.  i.  12-  first  temporo-sphenoidal  or  parallel  sulcus,  it  is 
^^-  necessary  to  find  two  bony  points — the  malar 

tubercle  and  the  lambda.  A  line  uniting  these  two 
points  corresponds  in  its  posterior  part  to  the  external 
parieto-occipital  sulcus,  and  in  its  middle  third  to  the 
first  temporo-sphenoidal  sulcus. 

The  Rolandic  fissure. — Take  a  point  \  inch  behind  the 

centre  of  a  line  drawn  across  the  vertex  of  the 
Fig.  i.,  4. 

skull  from  the  nasion  to  the  inion,  and  from 
this  point  draw  a  line  downwards  and  forwards  for  3I 
to  4  inches,  at  an  angle  of  67^°  (three-quarters  of  a  right- 
angle)  to  the  median  antero-posterior  line.  In  front  of 
this  sulcus  is  the  precentral  or  ascending  frontal  con- 
volution, an  area  better  known  as  the  Rolandic  or  motor 
area.  The  main  centres  here  situated  correspond,  from 
above  downwards,  to  the  movements  of  the  lower  extremity, 
upper  extremity  and  face  of  the  opposite  side  of  the  body. 
The  superior  temporal  crest  cuts  across  the  Rolandic  line 

.     .  at  the  junction  of  its  lower  and  middle  thirds, 

i-ig.  I.,  5. 

It  may  be  regarded  as  the  line  of  demarcation 

between  the  upper  extremity  area  above  and  the  face  area 

below. 

On  the  left  side  of  the  head,  that  part  of  the  brain  which 

is  included  in  the  obtuse  angle  between  the  anterior  and 

^.     .  posterior  horizontal  limbs  of  the  Sylvian  fissure  is 

Fig.  I.  ""  -^ 

known  as  Broca's  area  (the  motor  speech  centre). 

The  middle  meningeal  artery,  a  branch  of  the  internal 

maxillary,  enters  the  skull  through  the  foramen  spinosum, 

and  divides,  after  a  short  and  variable  course  across  the 


THE    HEAD    AND    NECK  7 

middle  fossa  of  the  skull,  into  two  main  trunks.     The  seat 

of   bifurcation   usually  corresponds   to  a  point 
Fig.  ii.,  3. 

just  above  the  centre  of  the  zygoma. 

The  anterior  branch  is  not  only  the  larger  of  the  two, 

..     ,      but  it  is  also  more  liable  to  injury,  since  it  is 
Fig.  II.,  4.  •'      •" 

protected    in    the   temporal   region   by  a  com- 
paratively thin  osseous  barrier. 

Fig.  ii.,  5,         The  danger  zone  in  the  course  of  this  branch 
'  may  be  mapped  out  by  taking  three  points : 

(i)  I  inch  behind  the  external  angular  frontal  process, 
and  I  inch  above  the  zygoma. 

(2)  ij  inches  behind  the  external  angular  frontal  process, 
and  i^  inches  above  the  zygoma. 

(3)  2  inches  behind  the  external  angular  frontal  process, 
and  2  inches  above  the  zygoma. 

A  line  uniting  these  three  points  indicates,  therefore, 
that  part  of  the  anterior  division  of  the  middle  meningeal 
artery  which  is  most  liable  to  injury. 

The  anterior  division  of  the  vessel  will  be  exposed  by 
trephining  over  any  of  these  three  points,  but  it  is  generally 
preferable  to  choose  the  highest  point,  as  by  such  means 
the  posterior  border  of  the  great  wing  of  the  sphenoid  is 
avoided  ;*  and,  as  an  additional  reason,  it  should  be 
added  that,  in  the  position  of  points  i  and  2,  the  artery 
frequently  runs  in  an  osseous  canal.  After  trephining  over 
the  upper  point,  the  bone  can  be  chipped  away  in  a  down- 
ward and  forward  direction,  if  such  an  exposure  of  the 
artery  is  deemed  necessary. 

The  posterior  branch  of  the  artery  passes  almost 
Fig.  ii.,  6. 

horizontally  backwards,  parallel  to  the  zygoma 
and  to  the  supramastoid  crest,  and  it  can    be   exposed 

♦  N.B. — This  point  will  be  better  understood  by  reference  to  the 
base  of  the  skull. 


8  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

by  trephining  over  a  point  where  a  vertical  Hne  drawn 

upwards  from  the  posterior  border  of  the 
Fig.  ii.,  7.  . 

mastoid  process  cuts  another  Hne  drawn  back- 
wards from  the  supra-orbital  margin  parallel  to  Reid's 
base  line. 

The   lateral   ventricles. — The    descending    cornu    of   the 

lateral  ventricle  may  be  tapped  by  trephining 

I5  inches  above  Reid's  base  line  and  ij  inches 
behind  the  external  auditory  meatus.  The  trocar  should 
be  directed  towards  the  summit  of  the  opposite  ear,  the 
ventricle  being  reached  within  2  inches  from  the  surface 
(Keen). 

The  basic  fosses. — "There  is  no  external  sign  to  indicate 
the  situation  of  the  fossae  of  the  skull.  In  general,  how- 
ever, it  may  be  said  that  the  anterior  fossa  extends  as  far 
back  as  the  anterior  end  of  the  zygoma ;  that  the  middle 
fossa  lies  between  this  and  the  mastoid  process,  and 
the  posterior  includes  all  the  base  behind  the  process" 
(Eisendrath). 

The  mastoid  antrum  may  be  exposed  by  trephining 
Fig.  ii.  12a.  ^^  Macewen's  suprameatal  triangle,  a  space  which 
'^'  "•'  'is  bounded  above  by  the  backward  continua- 
tion of  the  upper  root  of  the  zygoma  (the  supramastoid 
crest),  behind  by  a  vertical  line  drawn  upwards  from 
the  posterior  border  of  the  external  auditory  meatus, 
and  below  and  in  front  by  the  suprameatal  spine,  a 
prominent  bony  process  which  assists  in  the  formation  of 
the  posterior  superior  quadrant  of  the  external  auditory 
meatus.  In  this  triangle  there  is  usually  a  well-marked 
depression,  the  suprameatal  fossa.  The  supramastoid 
crest  not  only  indicates  the  uppermost  possible  limit  of 
the  mastoid  antrum,  but,  as  has  already  been  stated, 
it  corresponds  also  to  the  level  of   the  base  of   brain  in 


THE    HEAD    AND    NECK  g 

this  situation.     The  crest,  therefore,  represents  the  level 

of  the  tegmen   antri,  and,   in   mastoid  explora- 

■'     ■    tions,  the  scene  of  operation  must  be  confined  to 

an  area  below  this  crest.     In  the  adult  the  antrum  usually 

lies  at  a  depth  of  |  to  f  inch  from  the  surface. 

The  lateral  sinus  lies  posterior  and  nearer  to  the  surface, 
Fig.  ii.,  9.     whilst  the  facial  nerve  pursues  its  course  in  front 
ig.  II.,  12b.  ^^^  Qj^  ^  deeper  plane. 

The  parotid  gland  occupies  the  space  which  is  bounded 

above    by    the    zygomatic  arch,  behind  by  the 
Fig.  iii.,  5.  .   ,  ,     , 

auricle  and  the  mastoid  process,  and  below  by 

a  line  drawn  from  the  angle  of  the  jaw  to  the  apex  of  the 
mastoid  process.  In  front,  the  gland  extends  a  variable 
distance  over  the  anterior  surface  of  the  masseter  muscle. 
This  muscle  passes  downwards  and  backwards  from  the 
lower  border  of  the  zygomatic  arch  to  be  attached  to  the 
outer  surface  of  the  descending  ramus  and  angle  of  the 
lower  jaw.  When  the  teeth  are  clenched,  the  anterior 
border  of  the  muscle  is  easily  defined,  a  well-marked  line 
of  demarcation  being  so  formed  between  the  masseter 
muscle  behind  and  the  buccinator  in  front. 

Stejisen's  duct,  the  duct  of  the  parotid  gland,  corresponds 
to  the  middle  third  of  a  line  drawn  from  the 
lower  border  of  the  tragus  of  the  ear  to  a  point 
situated   half-way  between    the   ala  of  the  nose  and  the 
red  line  of  the  upper  lip.     At  the  anterior  border  of  the 
masseter    muscle    the    duct    dips    inwards,    through    the 
buccinator  muscle,  to  open  on  the  buccal  mucous  mem- 
brane, opposite  the  second  molar  tooth  of  the  upper  jaw. 
The  transverse  facial  artery,  a  branch  of  the  superficial 
temporal,  runs  inwards  parallel  to  and  imme- 
diately below  the  zygoma,  lying  above  the  level 
of  Stensen's  duct. 


10  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

The  facial  nerve,  after  emerging  from  the  stylo-mastoid 

foramen,  curls  round  the  condyle  of  the  jaw, 

'    '    and    traverses    the    substance   of    the   parotid 

gland,  in  which  part  of  its  course  it  divides  into  numerous 

branches.     The  general  transparotid  course  of  the  nerve 

and  the  direction  of  its  buccal  branch  may  be  indicated 

by  a  line  drawn  forwards  parallel  to  and  below  Stenson's 

duct  from  the  lobule  of  the  ear. 

The  inferior  dental  nerve  may  be  exposed  by  trephining 

over   the  ascending  ramus   of   the  lower  jaw, 

''    '    midway   between    the    anterior    and   posterior 

borders,  and  on   a  level  with   the  last  molar  tooth.     In 

this  manner,  the  nerve,  accompanied  by  the  corresponding 

artery,  is  exposed  as  it  enters  the  inferior  dental  canal. 

The  tonsil  corresponds  in   position  to  a  point  situated 

just   above  and   in  front   of   the  angle  of   the 
Fig.  iv.,3.     . 

lower  jaw. 

The  borders  of  the  hony  orbit. — The  following  bones  assist 
in  the  formation  of  the  orbital  margin : 
Above,  the  frontal  bone. 

Externally,  the  external  angular  frontal  process  and  the 
malar  bone. 

Below,  the  malar  bone  and  the  superior  maxilla. 
Internally,  the    nasal   process   of   the  superior  maxilla 
and  the  internal  angular  frontal  process. 

The  tendo  oculi  and  nasal  duct. — By  alternate  forcible 
closure   and  opening  of   the  lids,  the   internal 
'^"  ""     '    tarsal    ligament,    or    tendo   oculi,  can    be   felt 
passing    to    its    insertion    into    the  nasal    process  of   the 
superior  maxilla.     Immediately  below  the  tendon,  at  the 
junction  of  the  inner  and   lower  walls  of   the 
orbital  cavity,  is  the  depression  for  the  lachry- 
mal  sac,    which   sac   narrows  below  into  the  nasal  duct. 


THE    HEAD    AND    NECK  II 

The  duct  passes  downwards,  backwards  and  slightly  out- 
wards, to  open  into  the  anterior  part  of  the  inferior  meatus 
of  the  nose  under  cover  of  the  inferior  turbinated  bone. 
The  duct  is  about  ^-  inch  long. 

The  supra- orbital,  infra-orbital,  and  mental  foramina. — 
Figs,  iii.,  At  the  junction  of  the  inner  and  middle  thirds 
^■'  ■  of  the  supra-orbital  margin,  the  supra-orbital 
notch  or  foramen  may  be  felt,  and  a  line  drawn  down- 
w^ards  from  this  foramen  through  the  interval  between  the 
two  lower  bicuspid  teeth  will  pass  through  both  infra- 
orbital and  mental  foramina.  The  former  foramen  lies 
^  to  I  inch  below  the  orbital  margin,  whilst  the  latter  (in 
the  adult)  lies  midway  between  the  alveolar  and  inferior 
borders  of  the  lower  jaw. 

The  frontal  sinuses  are  very  variable  in  extent.  They 
occupy  the  space  between  the  inner  and  outer  tables  of 
the  frontal  bone,  above  the  base  of  the  nose  and  above 
the  inner  half  of  the  supra-orbital  margin.  The  sinus 
communicates  with  the  nasal  cavity  by  means  of  a  narrow 
channel,  the  infundibulum,  which  opens  into  the  middle 
meatus  of  the  nose  under  cover  of  the  middle  turbinated 
bone,  on  a  level  with  the  inner  margin  of  the  palpebral 
fissure. 

The  antrum  of  Highmore  usually  occupies  the  greater 
part  of  the  interior  of  the  superior  maxilla,  and  opens  into 
the  hiatus  semilunaris,  a  depression  which  lies  under  cover 
of  the  middle  turbinated  bone.  The  opening  is,  however, 
situated  at  so  high  a  level  that  pus  only  escapes  into  the 
nose  when  the  antrum  is  practically  full.  Two  teeth  are, 
on  the  other  hand,  closely  related  to  the  antrum — namely, 
the  second  bicuspid  and  the  first  molar  —  the  sinus 
usually  extending  downwards  in  the  interval  between 
the   two   labial   and    single    palatal    fangs   of    the   latter 


:  middle  meatus. 


12  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

tooth.  The  removal  of  either  of  these  teeth,  followed 
up  by  any  necessary  upward  boring,  will  efficiently  drain 
the  sinus. 

The  sinus  may  also  be  drained  by  everting  the  upper 
lip  and  puncturing  the  outer  wall  through  the  canine 
fossa,  a  depression  lying  above  the  canine  tooth. 

The  sphenoidal  sinus  occupies  the  greater  part  of  the 
body  of  the  sphenoid,  and  opens  into  the  spheno-ethmoidal 
recess,  a  space  lying  above  and  behind  the  superior 
turbinated  bone. 

The  sinuses  of  the  nose  and  their  efferent  channels  : 

The  sphenoidal  sinus  =  spheno-ethmoidal  recess. 

The  posterior  ethmoidal  cells  =  superior  meatus. 

The  anterior  ethmoidal  cells 

The  middle  ethmoidal  cells 

The  frontal  sinus 

The  antrum  of  Highmore 

The  nasal  duct  =  inferior  meatus. 

The  Triangles  of  the  Neck. 

The  lateral  aspect  of  the  neck  is  divided  by  the  sterno- 

mastoid  muscle  into  two  triangles — anterior  and  posterior. 

The  anterior  triangle  is  bounded  in  front  by  the  middle 

line  of  the  neck,  behind  by  the  anterior  border 

of  the  sterno-mastoid  muscle,  and  above  by  the 

lower  border  of  the  ramus  of  the  jaw. 

The  space  so  marked  out  is  divided  into  three  smaller 
triangles  by  the  digastric  muscle  and  by  the  anterior  belly 
of  the  omo-hyoid : 

(i)  The  submaxillary  triangle,  above  the  digas- 
Fic  iv.   17» 

trie  muscle,  containing  the  submaxillary  gland. 

(2)  The    muscular   triangle,    anterior   to   the 
Fig.  iv.,  19. 

omo-hyoid  muscle. 


THE    HEAD   AND    NECK  I3 

(3)  The  carotid  triangle,  bounded  above  by  the  posterior 
belly  of   the  digastric,  behind  by  the  anterior 
''     '   border   of   the   sterno-mastoid   muscle,   and   in 
front  by  the  anterior  belly  of  the  omo-hyoid.     In  this  tri- 
angle  the   common   carotid   bifurcates,  and  the   external 
carotid  gives  off  most  of  its  branches. 

The    posterior   triangle    is    bounded    in    front    by   the 
posterior   border   of   the   sterno-mastoid,  behind   by  the 
Fig.  iv.,  15,  anterior  border  of  the  trapezius,  and  below  by 
^^  the  middle  third  or  fourth  of  the  clavicle.     The 

triangle  is  subdivided  by  the  posterior  belly  of  the  omo- 
hyoid, which  cuts  off  the  small  subclavian  triangle  below 
from  the  more  extensive  occipital  triangle  above. 

The  Vessels  and  Nerves. 

The   carotid  arteries  correspond  in  direction  to  a  line 

from  the  sterno-clavicular  joint  to  the  hollow 

"S-  '"•.    •    between  the  angle  of  the  jaw  and  the  mastoid 

process.      The  common  carotid  usually  bifurcates  at   the 

level  of  the  upper  border  of  the  thyroid  cartilage  (fourth 

p;«r  :::  in  cervical  vertebra),  the  external  carotid  subse- 
r  ig.  III. I  i\j, 

'^-  quently  lying  superficial  to  and  slightly  to  the 

inner  side  of  the  internal  carotid.  The  omo-hyoid  muscle 
(upper  belly)  crosses  the  common  carotid  at  the  level  of 
the  cricoid  cartilage,  and  in  this  situation  the  artery  may 
be  compressed  against  the  prominent  anterior  tubercle 
of  the  transverse  process  of  the  sixth  cervical  vertebra 
(Chassaignac's  tubercle). 

The   superior   thyroid   artery   arises   from    the   external 

carotid  in   the   carotid  triangle,    immediately  above   the 

level  of  the  upper  border  of  the  thyroid  carti- 

F'g-  '"•.  12.  j^g^^  ^^j^  turning  downwards  under  cover  of 

the  anterior  belly  of   the  omo-hyoid   muscle,  is  directed 

2 


14  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

towards  the  apex  of  the  lateral  lobe  of  the  thyroid 
gland. 

The  lingual  artery  arises  midway  between  the  level  of 
the  upper  border  of  the  thyroid  cartilage  and  the  great 
Fig.  iii.,  13.  cornu  of  the  hyoid  bone,  and  enters  the  sub- 
Fig,  v.,  7.  maxillary  triangle  by  passing  deep  to  the 
posterior  belly  of  the  digastric  muscle.  The  artery  so 
gains  the  upper  border  of  the  hyoid  bone,  and  runs  in- 
wards for  a  short  distance  parallel  to  that  bone  under 
cover  of  the  hyo-glossus  muscle. 

The  facial  artery  arises  opposite  the  great  cornu  of  the 

hyoid  bone,  and  also  enters  the  submaxillary  triangle  by 

passing  deep  to  the  posterior  belly  of  the  digas- 
Fig.  iii    14 

■'     "  trie.      In   this   triangle  the   artery  lies  deeply 

embedded  in  the  substance  of  the  submaxillary  salivary 
gland,  and  then  enters  on  its  facial  course  by  curling  round 
the  inferior  border  of  the  lower  jaw  immediately  anterior 
to  the  masseter  muscle,  about  i|  inches  in  front  of  the 
angle  of  the  jaw.  The  vessel  then  passes  upwards  towards 
the  inner  canthus  of  the  eye,  there  terminating  as  the 
"  angular  artery." 

The  occipital  artery  arises  from  the  outer  side  of  the 
external  carotid  artery  in  the  upper  part  of  the  carotid 
triangle,  and  passes  upwards  and  backwards, 
under  cover  of  the  posterior  belly  of  the  digas- 
tric muscle,  towards  the  interval  between  the  mastoid 
process  and  the  transverse  process  of  the  atlas.  At  the 
apex  of  the  posterior  triangle  the  artery  is  joined  by  the 
great  occipital  nerve  (posterior  primary  division  of  the 
second  cervical  nerve),  the  two  structures  then  passing 
upwards  on  to  the  vault  of  the  skull. 

The  posterior  auricular  irtery  arises  from  the  external 
carotid,   immediately  above   the   posterior   belly   of    the 


THE  SIDE  OF  THE  FACE  AND  NECK 


FIG.   III. 

1.  The  supra-orbital  foramen.  13.  The 

2.  The  infra-orbital  foramen.  14.  The 

3.  The  mental  foramen.  15.  The 

4.  The  zygoma.  16.  The 

5.  The  parotid  gland.  17.  The 

6.  The  transverse  facial  artery.  pi 

7.  Stensen's  duct.  iS.  The 

8.  The  facial  nerve.  19.  The 

9.  The  common  carotid  artery.  20.  The 

10.  The  external  carotid  artery.  21.  The 

11.  The  internal  carotid  arter}'.  22.  The 

12.  The  superior  thyroid  artery.  23.  The 


lingual  artery. 

facial  artery. 

interna]  jugular  vein. 

external  jugular  vein. 

upper  limit  of  the  brachial 

exus. 

subclavian  artery. 

clavicle. 

manubrium  sterni. 

gladiolus  sterni. 

angle  of  Ludwig. 

first  costal  cartilage. 

To  face  Fi^.  IV.,pfi.  14,  15. 


THE  SIDE  OF  THE  FACE  AND  NECK 


F^IG. 


1.  The  inferior  maxilla. 

2.  The  inferior  rlental  nerve. 

3.  The  tonsil. 

4.  The   transverse  process  of  the 

atlas. 

5.  5.  The  spinal  accessory  nerve. 

6.  The  sterno-mastoifl  muscle. 

7.  The  upper  limit  of  the  brachial 

plexus. 
H.  The    third     part    of    the    sulj- 

clavian  artery. 
9.  Tlie  clavicle. 


IV. 
10. 


The  clavicular  head  of  the 
sterno-mastoid  muscle. 

The  sternal  head  of  the  sterno- 
mastoid  muscle. 

The  digastric  muscle. 

The  omohyoid  muscle. 

The  trapezius  muscle. 

The  posterior  trianjj^le. 

The  carotid  trian,i(le. 

The  submaxillary  triangle. 

Tlie  subclavian  triangle. 

The  muscular  triangle. 

To  face  lut;.  ///.,//.  14,  15. 


THE    HEAD    AND    NECK  I5 

digastric  muscle,  and  passes  backwards  parallel  to  the 
upper  border  of  that  muscle,  through  the  lower 
'^"  '^'  part  of  the  parotid  gland,  to  the  depression 
between  the  cartilage  of  the  concha  of  the  ear  and  the 
mastoid  process.  Here  the  artery  is  joined  by  the  posterior 
auricular  nerve — a  branch  of  the  facial. 

The  superficial  temporal  artery  arises  in  the  substance  of 
the  parotid  gland  as  one  of  the  two  terminal  branches  of 
the  external  carotid.  It  crosses  the  base  of  the  zygomatic 
process  of  the  temporal  bone,  immediately  in  front  of  the 
tragus  of  the  ear,  and  is  accompanied  by  the  auriculo- 
temporal nerve,  a  sensory  branch  of  the  third  division  of 
the  fifth  cranial  nerve. 

The  subclavian  artery  (cervical  course)  is  represented  by 
Fig.  iii.  18.  ^  curved  line  from  the  sterno-clavicular  joint 
Fig.  IV.,  8.  ^y  ^]^g  mid-point  of  the  corresponding  clavicle, 
the  convexity  of  the  line  extending  upwards  into  the 
supraclavicular  fossa  about  f  to  i  inch  above  the  clavicle. 
In  marking  out  this  vessel,  the  shoulders  should  be  well 
depressed. 

The  artery  passes  behind  the  scalenus  anticus  muscle, 
the  second  part  of  the  artery  being  covered  by  that  muscle. 
The  outer  border  of  the  scalene  muscle  usually  corresponds 
to  the  outer  border  of  the  sterno-mastoid  muscle,  and 
consequently  the  third  part  of  the  subclavian  artery  is 
represented  by  that  part  of  the  curve  which 
ig.  IV.,  .  j.^^  between  the  outer  border  of  the  sterno- 
mastoid  muscle  and  the  mid-point  of  the  clavicle. 

The  subclavian  artery  ends  anatomically  at  the  outer 
border  of  the  first  rib. 

The  external  jugular  vein  is  formed  just  behind  the  angle 
of  the  jaw  by  the  junction  of  the  posterior  division  of  the 
temporo-maxillary  trunk  with  the  posterior  auricular  vein. 

2 — 2 


l6  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

The  vessel  so  formed  passes  downwards  and  backwards, 
superficial    to    the    sterno-mastoid    muscle,   to- 
wards the  middle  of  the  clavicle,  above  which 
bone  the  vein  pierces  the  deep  fascia  to  join  the  subclavian 
vein. 

The  internal  jugular  vein  runs  parallel  and  external  to 
the  internal  and  common  carotid  arteries,  and 
'     '  therefore  presents  a  similar  surface  marking  to 
that  already  given  for  those  arteries. 

The  vagus  nerve  passes  downwards  in  the  carotid  sheath, 
behind  and  between  the  carotid  arteries  and  the  internal 
jugular  vein. 

The  cervical  sympathetic  trunk  also  lies  in  the  line  of  the 
carotid  arteries,  being  placed  behind  the  carotid  sheath. 
The  superior  cervical  ganglion  is  situated  in  front  of  the 
transverse  processes  of  the  second  and  third  cervical 
vertebrae ;  the  middle  ganglion  overlies  the  corresponding 
process  of  the  sixth  vertebra ;  whilst  the  inferior  ganglion, 
which  is  frequently  fused  with  the  first  thoracic,  lies 
behind  the  first  part  of  the  subclavian  artery,  between 
the  transverse  process  of  the  seventh  cervical  vertebra 
and  the  neck  of  the  first  rib. 

The  phrenic  nerve  is  formed  below  the  level  of  the  hyoid 
Fig.  iv.  (un-  bone  by  branches  from  the  anterior  primary 
between  divisions  of  the  third,  fourth  and  fifth  cervical 
nerves,  and  passes  downwards  and  slightly 
inwards  towards  the  sternal  end  of  the  clavicle.  At  the 
level  of  the  cricoid  cartilage  the  nerve  lies  midway  between 
the  anterior  and  posterior  borders  of  the  sterno-mastoid 
muscle. 

The  spinal  accessory  nerve  crosses  the  transverse  process 
of  the  atlas,  a  bony  prominence  to  be  felt  immediately 
below  and  in  front  of  the  apex  of  the   mastoid  process. 


THE    HEAD    AND    NECK  I7 

The  nerve  enters  the  substance  of  the  sterno-mastoid 
Fig.  iv.,  4,    ^^  ^^^  junction  of  the  upper  and  second  quar- 

5.  5.  ters  along  the  anterior  border  of  the  muscle, 
emerging  from  the  posterior  border  of  the  muscle  at 
the  junction  of  the  upper  and  middle  thirds.  The  point 
of  emergence  is,  however,  subject  to  some  variation,  and 
the  nerve  may  enter  the  posterior  triangle  of  the  neck  at 
a  somewhat  lower  level,  pursuing  subsequently  a  down- 
ward and  backward  course  towards  the  anterior  border 
of  the  trapezius  muscle,  beneath  which  muscle  it  sinks.* 

The  superficial  cervical  plexus. — Take  a  point  midway 
along  the  posterior  border  of  the  sterno-mastoid  muscle, 
and  from  this  point  draw  three  lines : 

1.  Upwards  towards  the  lobe  of  the  ear  =  the  great 
auricular  nerve  (2  and  3  C). 

2.  Upwards  along  the  posterior  border  of  the  sterno- 
mastoid  muscle  =  small  occipital  nerve  (2  C). 

3.  Forwards  towards  the  middle  line  of  the  neck  =  the 
transverse  cervical  nerve  (2  and  3  C.)- 

By  producing  these  three  lines  in  a  downward  direc- 
tion, the  descending  branches  of  the  plexus  are  roughly 
indicated. 

Thus  the  great  auricular  produced  =  the  supraclavicular 
nerve;  the  small  occipital  produced  =  the  suprasternal 
nerve ;  the  transverse  cervical  produced  =  the  supra- 
acromial  nerve.  The  three  descending  trunks  are  derived 
from  the  third  and  fourth  cervical  nerves,  and  all  the 
branches  of  this  plexus  arise  from  the  anterior  primary 
divisions  of  their  respective  nerves. 

*  Another  surface-marking  for  the  spinal  accessory  nerve. — Draw  ;i 
line  from  a  point  midway  between  the  tip  of  the  mastoid  process  and 
the  angle  of  the  jaw  to  the  middle  of  the  posterior  border  of  the 
sterno-mastoid  muscle,  and  thence  across  the  posterior  triangle  to  the 
anterior  border  of  trepezius. 


l8  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

The  brachial  plexus. — The  upper  limit  of  the  nerve- 
Fig,  iii.,  17.  trunks  which  form  this  plexus  is  represented 
'^'  '^■'  ■  by  a  line  drawn  from  the  mid-point  between 
the  anterior  and  posterior  borders  of  the  sterno-mastoid 
muscle  at  the  level  of  the  cricoid  cartilage  to  a  second 
point  situated  just  external  to  the  mid-point  of  the  clavicle. 
The  lowest  cord  lies  behind  the  third  part  of  the  sub- 
clavian artery. 

The  rinia  glottidis,  which  in   its  front  part  is  laterally 

bounded  by  the  true  vocal  cords,  lies  opposite 

Fiff   V     10  .  . 

the  mid-point  along  the  anterior  border  of  the 

thyroid  cartilage. 

The  epiglottis,  though  fixed  below  to  the  thyroid  angle 
immediately  above  the  point  of  attachment  of 
"     the  true  vocal  cords,  extends  upwards  to  above 
the  level  of  the  body  of  the  hyoid  bone, 

A  suicidal  cut-throat  frequently  involves  the  thyro-hyoid 
space,  and  the  epiglottis  may  be  severed  from  its  thyroid 
attachment. 

The  isthmus  of  the  thyroid  gland   crosses   the   trachea 
Fig.  v.,  12.    about  I  to  f  inch  below  the  cricoid  cartilage. 
Fig.  V.  The  structures  in  the  middle  line  of  the  neck  : 

(i)  Passing  down  from  the  jaw  to  the  body  of  the  hyoid 
bone,  the  two  genio-hyoid  muscles  lie  each  side  of  the 
middle  line.  They  are  placed,  however,  deep  to  the  mylo- 
hyoid muscles,  which  are  directed  downwards  and  inwards 
to  the  m.edian  raphe  and  to  the  body  of  the  hyoid  bone. 
(2)  The  body  of  the  hyoid  bone.  (3)  The  thyro-hyoid 
space.  (4)  The  thyroid  cartilage.  (5)  The  crico-thyroid 
space.  (6)  The  cricoid  cartilage.  (7)  The  upper  two  or 
three  tracheal  rings.  (8)  The  isthmus  of  the  thyroid  gland, 
(g)  The  trachea.     (10)   The  suprasternal  notch. 


THE  FRONT  OF  THE  NECK 


FIG.  V. 


1.  The  supra-orbital  foramen. 

2.  The  infra-orbital  foramen. 

3.  The  mental  foramen. 

4.  The  j<enio-hyoifl  muscle  ((leej) 

to  the  mylo-hyoid  muscle). 

5.  The  digastric  muscle. 

6.  The  mylo-hyoiil  muscle. 


7.  The  liNO-glossus  muscle. 
<S.  The  liyoid  bone. 
9.  The  epiglottis. 

10.  The  thjroid  cartilage. 

11.  u.  The  trachea. 

12.  The  thyroid  isthmus. 

13.  The  sternum. 

To  /ace  p.  18. 


CHAPTER  II 
THE    UPPER    EXTREMITY 

In  this  chapter,  and  in  that  on  the  lower  extremity,  the 
reader's  attention  is  mainly  directed  to  those  bony  promi- 
nences and  muscular  or  tendinous  elevations  which  lie  in 
the  region  of  the  joints,  since  these  form  the  more 
important  landmarks  which  aid  in  the  representation  of 
the  arteries,  nerves,  etc.,  of  the  limbs.  The  muscular 
masses,  which  complete  the  symmetry  of  the  arm  or  leg 
between  the  joints,  are  only  mentioned  where  necessary,  a 
fair  general  knowledge  of  the  anatomical  structure  of  the 
body  being  assumed. 

The  shoulder  region. — The  acromial  process,  the  spine 
of  the  scapula  and  the  clavicle,  being  subcutaneous 
throughout  their  whole  length,  can  readily  be  palpated 
from  end  to  end.  The  clavicle  should  first  be  examined 
from  its  blunted  sternal  extremity  to  the  acromio-clavicular 
joint.  The  inner  third  of  the  shaft  is  rounded  and 
presents  a  marked  forward  convexity,  whilst  the  outer 
third  of  the  bone  is  flattened  from  before  backwards  and 
shows  a  concave  anterior  border.  At  the  outer  end  of  the 
bone  a  slight  elevation  can  usually  be  felt  on  the  superior 
surface,  and  immediately  external  to  this  is  the  acromio- 
clavicular joint,  the  long  axis  of  which  lies  in  the  antero- 
posterior direction, 

»9 


20  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

The   acromial   spine   is   narrow    at    about   its    centre, 

broadening    out    towards    the    vertebral    border   of    the 

scapula,  and  forming  there  a  smooth  triangular 

Fig.  xiii.,  1.  ,.,,.,,  ,.  ^ 

surrace,  over  which  glides  the  tendinous  part  or 
the  trapezius.  Externally,  the  spine  terminates  in  the 
upward  curved  acromial  process,  at  the  anterior 
''  "  border  of  which  an  oval  facet  is  situated  for 
articulation  with  the  clavicle.  The  supra-  and  infra- 
spinatus muscles  fill  up  the  depressions  or  fossae  which  lie 
in  relation  to  the  spine  of  the  acromion. 

The  clavicle  is  also  bounded  above  and  below  by 
depressions,  little  evident  in  fat  subjects,  but  most  marked 
when,  as  the  result  of  pathological  or  physiological  condi- 
tions, fat  is  feebly  represented.  The  supra- 
'  clavicular  or  subclavian  triangle  is  dealt  with 
in  the  first  chapter.  The  mfraclavicular  space  is  bounded 
above  by  the  clavicle,  below  by  the  clavicular  head  of  the 
pectoralis  major  muscle,  internally  by  the  costal  cartilage 
of  the  first  rib,  and  externally  by  the  anterior  border  of  the 
deltoid  muscle.  The  floor  is  formed  by  the  subclavius 
muscle  and  the  costo-coracoid  membrane.     In  the  outer 

part  of  the  space  the  coracoid  process  may  be 
Ficr,  vi     3. 

''    '    felt,  the  apex  of  the  process  lying  under  cover 

of  the  anterior  border  of  the  deltoid  muscle.  In  favourable 
cases,  the  pulsation  of  the  axillary  artery  (Part  I.)  may  be 
detected  below  the  clavicle,  as  this  vessel  runs  downwards 
from  the  outer  border  of  the  first  rib.  The  bulky 
''  '  deltoid  muscle,  arising  from  the  clavicle  and  from 
the  acromial  process  and  spine,  is,  so  to  speak,  pushed 
outwards  by  the  underlying  head  and  great  tuberosity 
of  the  humerus,  so  producing  the  normal  rounded  appear- 
ance of  the  shoulder.  This  outward  displacement  of  the 
muscle  is  taken  advantage  of  by  Hamilton  in  the  diag- 


^     £ 


of  1 

nerv 
artei 
artei 

,            ,— 1  ,__i     !_,  .J. 

;-( 

leve 
dius. 
radia 
radia 
ulna: 

nied 

03 

a 

(U  2  aj  oj  4;  a; 

§  ^ 

H      HHHH 

H 

lO       \0   I-^X    On 

d 

M  „     M     l-i     I-  CS 


rdr::;  C^ 


^t,.2 

a       c; 

V-.  o;  "^ 

C     .5 

^^'-3 

'^  fc^.si 

•— '  "rJ  cj 

>  <u  ^,  o 

'E^s 

C  -H  U  tn 

n  ne 
al  ar 
nerv 
s  mu 

g.2  A 

V^    (U    rt 

.2^   iH   Oh 

m   -M     1_ 

rr-      (J      Cd      IJ 

■^  SS  o 

£  rt  o.y 

n  o  o 

dj 

E  i-";:  n 

03     Oh" 

CJ 

c,c  3  i: 

OJ    U    lU 

5 

11    (U    (U    OJ 

HHH 

HHHH 

CO    CTv  O         hH   M   CO-* 


nJ         O   S   <U  ^ 

03  t;  o  '-'  b  '-' 


^  ;;  1-  9-r  s 


<]J   OJ   <u 


a;   O   D 


THE    UPPER    EXTREMITY  21 

nosis  of  a  dislocation  of  the  shoulder-joint,  as,  after  such 
an  injury,  the  humerus  is  drawn  inwards  by  the  pectoralis 
major,  latissimus  dorsi  and  other  muscles  to  such  a  degree 
that  a  ruler  placed  along  the  outer  side  of  the  arm  will  be 
in  contact  with  the  acromion  process  and  the  external 
humeral  condyle  at  one  and  the  same  time.  In  the 
normal  condition,  this  is  not  possible. 

To  measure  the  length  of  the  humerus,  the  tape-measure 
Fig.  xiv.,  4,  should  be  carried  from  the  lower  margin  of  the 
acromial  process  to  the  external  condyle  of  the 
humerus.  The  lesser  tuberosity  of  the  humerus  is  always 
difficult  to  identify,  but  it  can  usually  be  distinguished 
lying  rather  below  the  mid-point  of  a  line  uniting  the 
coracoid  process  and  the  great  tuberosity  of  the  humerus, 
the  arm  being  well  everted  and  the  elbow  in  contact  with 
the  side  of  the  body. 

Between  the  two  tuberosities  is  the  bicipital  groove,  in 
which  runs  the  long  tendon  of  the  biceps  muscle.  The 
groove  may  be  represented  by  a  line,  about  2  inches  long, 
which  runs  downwards  from  the  tip  of  the  acromial 
process,  parallel  to  the  long  axis  of  the  humerus. 

The  upper  epiphysis  of  the  humerus  includes  the  head 
and  both  tuberosities,  and  the  epiphysial  line  runs  trans- 
versely, at  right  angles  to  the  long  axis  of  the  humerus,  at 
the  lower  border  of  the  great  tuberosity. 

The  axilla. — To  examine  this  space,  the  elbow  should 
be  supported,  and  the  patient  instructed  to  relax  all 
muscles.  The  anterior  wall  is  formed  by  the  major  and 
minor  pectoral  muscles,  and  by  the  costo-coracoid  mem- 
brane The  pectoralis  major  alone  forms  the  anterior 
fold  of  the  axilla,  and  does  not  extend  as  far 
'^"  ^'  '  downwards  as  the  posterior  fold,  whilst  its 
rounded  appearance  results  from  the  twisting  of  the  fibres 


22  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

of  the  pectoral  muscle  before  their  insertion  into  the  outer 
bicipital  ridge.  The  posterior  wall  is  formed  mainly  by 
the  subscapularis  muscle  overlying  the  ventral  surface  of 
the  scapula,  the  axillary  border  of  which  bone  can  be  made 
out  by  deep  palpation  from  the  inferior  angle  below  to  the 
head  above.  The  rounded  posterior  fold  of  the  axilla  results 
from  the  fact  that  the  latissimus  dorsi  curls  round  the 
Fig.  vi.,9.  teres  major  muscle  from  behind  forwards  in 
Fig.  XIII.,  7.  Qj-fjgi-  ^o  reach  its  insertion  into  the  floor  of  the 
bicipital  groove.  The  narrow  outer  boundary  of  the  axilla 
corresponds  to  the  upper  part  of  the  shaft  and  to  the  head 
of  the  humerus,  and  in  this  situation,  in  a  well-developed 
arm,  two  prominent  longitudinal  folds  are  seen, 
the  anterior  of  which  corresponds  to  the  coraco- 
brachialis  and  biceps  (short  head)  muscles,  whilst  the 
Fig.  vi.,  1  -  more  posterior  fold  results  from  the  projection 
of  the  neuro-vascular  bundle.  The  head  of  the 
humerus  and  of  the  scapula  can  be  felt  at  the  upper  and 
posterior  part  of  the  axilla,  the  second  rib  on  the  inner 
side,  and  the  coracoid  process  in  front.  The  head  of  the 
humerus  looks  in  the  same  direction  as  the  internal 
condyle  of  the  humerus.  The  inner  wall  of  the  axilla  is 
formed  by  the  upper  part  of  the  lateral  wall  of  the  thorax, 
which  is  here  clothed  by  the  serrations  of  the  serratus 
magnus  muscle. 

The  axillary  lymphatic  glands  are  arranged  in  three  main 
groups,  all  converging  towards  the  apex  of  the  axilla  : 

(a)  The  pectoral  set,  running  upwards  and  outwards 
under  cover  of  the  outer  border  of  the  pectoral  muscles 
and  draining  the  anterior  and  lateral  aspects  of  the  chest- 
wall  and  the  abdomen  above  the  level  of  the  umbilicus. 

(b)  The  subscapular  set,  running  upwards  along  the 
axillarv  border  of  the  subscapularis  muscle,  and  draining 


6-5li 


K^       0)    ^    J3 


I— 1 

> 

<     . 

f) 

1— 1 

w  . 

Ph 

ffi  S 

£H 


S  5  2' 


O  rt- 


K  1)     (LI     0) 


THE    UPPER    EXTREMITY  23 

the  lateral  and  posterior  aspect  of  the  chest  above  the 
level  of  the  umbilicus. 

(c)  The  brachial  and  axillary  set,  running  upwards  in 
the  line  of  the  axillary  vessels,  and  draining  the  whole  of 
the  upper  extremity. 

The  elbow  region. — When  the  forearm  is  extended,  a 
pjg.  yjj  line  joining  the  internal  and  external  condyles 
of  the  humerus  cuts  across  the  tip  of  the  ole- 
cranon process,  which  bony  prominence  lies  w^ell  to  the 
inner  side  of  the  mid-point  of  the  intercondyloid  line. 
When  the  forearm  is  flexed,  the  olecranon  moves  down- 
wards, and  by  uniting  the  three  bony  points  a  triangle  is 
Fig.  xiii.       formed.     Immediately  below  the  external  con- 

^'  ^-  dyle  the  head  of  the  radius  is  felt  "  lying  in  the 

valley  behind  the  supinator  longus "  (Holden).  The 
humero-radial  articulation  is  transverse,  but  the  humero- 
ulnar  articulation  slopes  obliquely  downwards  and 
inwards,  and  consequently,  whilst  the  external  condyle  is 
about  f  inch  above  the  humero-radial  joint,  the  internal 
condyle  lies  rather  more  than  i  inch  above  the  line  of  the 
humero-ulnar  articulation. 

The  junction  of  the  dtaphysis  and  lower  epiphysis  of  the 
humerus  corresponds  to  a  transverse  line  drawn  across 
the  humerus  immediately  above  the  tips  of  the  condyles. 
The  bony  points  on  the  outer  side  of  the  joint  are  generally 
obscured  in  those  cases  where  there  is  considerable  effusion 
into  the  elbow-joint,  the  synovial  membrane  bulging  out- 
wards below  the  external  condyle  of  the  humerus  and 
between  that  process  and  the  olecranon  process.  Under 
similar  conditions,  there  is  also  an  outward  projection  of 
the  synovial  membrane  between  the  olecranon  and  the 
internal  condyle  of  the  humerus,  obscuring  the  deep 
depression  that   normally  exists  in  that  situation — a  de- 


24  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

pression  at  the  base  of  which  the  ulnar  nerve  can  be  rolled 
beneath  the  finger. 

In  front  of  the  elbow  is  the  antecuhital  triangle,  the  base 

of  which  corresponds  to  a  line  drawn  across  the 

■'  ■  front  of  the  elbow  between  the  two  humeral 

condyles,  whilst  the  inner  and  outer  boundaries  are  formed 

Fig.  viii.,      respectively   by   the   pronator    radii   teres   and 

supinator    longus    muscles.       This    triangular 

space   is    vertically   subdivided   by   the    biceps 

''    '  tendon,  on  either  side  of  which  a  depression 

exists,  the  inner  and  outer  bicipital  sulci.      In  the  outer 

sulcus  the  musculo-spiral  nerve  divides  into  its 

'^"  ^'"■'    ■  two   terminal   branches,    radial    and    posterior 

interosseous,  whilst  the   median   nerve  and  the  brachial 

pj     yjjj        artery  lie  in  the  inner  sulcus,  the  artery  inter- 

^'  ^'  mediate  between   the   tendon    and   the   nerve. 

The  artery  and  nerve  are,  however,  obscured  in  the  lower 

part  of   the  inner  sulcus  by  the  overlying  bi- 

ig.  VIII.,    .  ^jpj^g^j    fascia,   which    can   be   traced    inwards 

to   the   pronator   region,   whilst    its    upper   free    margin 

presents    a   well  -  marked    crescentic    edge   which    looks 

upwards  and  inwards. 

The  superficial  veins  in  front  of  the  bend  of  the  elbow 

are  arranged  in  the  form  of  a   letter  M,  the 

'^'  "^'         radial,  median  and  ulnar  veins  being  received 

from  below,  whilst  two  main  efferent  vessels,  the  cephalic 

and  the  basilic,  carry  the  blood  upwards,     The 

'  '  ■'    ■    basilic  vein  passes  upwards  in  the   superficial 

fascia,  along  the  inner  side  of  the  arm,  and  pierces  the 

deep  fascia  about   half-way  between  the   axilla  and  the 

internal  condyle,  and  at  the  foramen  so   pro- 

'  '^''     '  duced  in  the  deep  fascia  the  internal  cutaneous 

nerve  emerges  to   become   superficial.      The  epitrochlear 


> 

C 
W 

w 


.  •'-   l>   ;-. 

^ 

S  -^  J3   rt 

>^ 

'J  ^   d  " 

.-;:  n  oj  i 

rt  0  ^c^ 

oj  oj--  a; 


4J  -X. 
y  is 


y. 

:sif5 

'"' 

H  V  y  ^^  fe 

o 

"toll's 

1— I 

"!  a;  i  C.2 

ti";^-^     !-.     CLI 

0  x/  ii  s  o 

P^P  S  cfl  a, 

(U  ^u   OJ  (U  <l> 

oj  1)  ?i  u  aj 


/^ 


THE    UPPER    EXTREMITY  25 

gland  lies  in  close  connection  with  the  median  basilic  or 

basilic  veins  above  and  in  front  of  the  internal 
Fig.  ix.,  11.  J    , 

condyle. 

The  cephalic  vein  can  be  traced  upwards  along  the  outer 

side  of  the  arm  as  far  as  the  groove  between 
Fie.  ix,   4.  . 

the  deltoid  and  pectoralis  major  muscles.     In 

the    interval    between    these    two    muscles   the   vein    lies 

embedded,  and   eventually   pierces   the   costo- 

'    ■    coracoid  membrane  in  the  infraclavicular  region 

to  open  into  the  axillary  vein. 

The  Region  of  the  Wrist  and  Hand. 
Two  tendons  only  are  conspicuous  at  the  front  of  the 
Fig.  X.,         wrist — the  palmaris  longus  in  the  middle  line, 
^'  '■  and  the  flexor  carpi  radialis  to  the  outer  side 

of   the   palmaris  longus.      The  flexor  carpi  ulnaris  can, 
however,  be  distinguished  by  palpation  along  the  ulnar 
Fig.  X.,         border  of  the  forearm,  and  can  be  traced  down- 
4-.  5.  wards  to  its  insertion  into  the  pisiform  bone. 

Between  the  palmaris  longus  and  the  flexor  carpi  ulnaris 
the  main  mass  of  the  flexor  sublimis  digitorum  lies.     Two 
transverse  creases  are  seen  in  this  situation,  the 
upper  of  which  roughly  corresponds  to  the  level 
of  the  radio-carpal  joint,  whilst  the  lower  represents  almost 
exactly  the  upper  limit  of  the  anterior  annular  ligament. 
Just  external  to  where  the  flexor  carpi  radialis  tendon 
cuts  across  the  two  transverse  creases  there  is  a 
'    '    depression,  in  the  floor  of  which  the  lower  end 
of  the  radius  and  the  tubercle  of  the  scaphoid  bone  may 
be  felt.     The  radial  artery  crosses  this  space  in  a  down- 
ward  and  outward  direction.     The  trapezium 
lies  at  the  lower  limit  of  the  depression,  imme- 
diately  below   and   external  to  the  scaphoid  tuberosity. 


26  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

The   prominent    pisiform   bone  can  be  distinguished  by 

tracing   downwards   the   tendon   of   the  flexor 

''  '     carpi  ulnaris  muscle,  and  posterior  to  this  bone 

both  cuneiform  and  unciform  bones  are  situated.    A  finger's 

breadth    below   and   external    to   the    pisiform 

bone  deep  palpation  will  verify  the  position  of 

the  hook  of  the  unciform  bone. 

The  anterior  annular  ligament  is  attached  to  four  bony 

points,  two   on  the  radial    side,  the   scaphoid 

tubercle  and  the  ridge  on  the  trapezium,  and 

two  on  the  ulnar  side,  the  pisiform  and  the  hook  of  the 

unciform.     The  upper  limit  of  the  ligament  corresponds 

to  the  lower  of  the  two  transverse  creases  in 

front  of  the  wrist,  whilst  the  inferior  limit  of  the 

ligament  lies  about  f  inch  below. 

The  flexor  synovial  sheaths. — The  flexor  longus  pollicis, 
the  flexor  sublimis  and  the  flexor  profundus 
'^'  '■  digitorum  all  pass  beneath  the  anterior  annular 
ligament.  In  this  situation  the  flexor  sublimis  consists  of 
four  tendons,  of  which  the  medius  and  annularis  lie  super- 
ficial to  the  tendons  which  pass  to  the  index  and  little 
fingers.  The  profundus  consists  of  two  parts  only, 
the  tendon  to  the  index-finger  being  alone  differentiated 
off  from  the  main  mass.  Beneath  the  ligament  these 
tendons  are  surrounded  by  two  synovial  sheaths,  one  for 
the  flexor  longus  pollicis  and  one  for  the  remaining  tendons 
plus  the  median  nerve.  The  sheaths  extend  upwards 
about  I  inch  above  the  upper  limit  of  the  ligament,  and 
therefore  the  same  distance  above  the  lower  transverse 
pj     ^j  crease  in  front  of  the  wrist.     The  flexor  longus 

®'  pollicis  sheath  is  continued  downwards  to  the 

insertion  of  the  tendon  into  the  distal  phalanx  of   the 
thumb.     The  main  sheath  broadens  out  below  the  liga- 


FIG.  X. 

1.  The  flexor  carpi  radialis. 

2.  The  palmaris  longus. 

3.  The  ulnar  artery. 

4.  The  flexor  carpi  ulnaris. 

5.  The  pisiform  bone. 

6.  The  transverse  creases  of  the  wrist. 

7.  The  superficial  branch  of  the  ulnar  artery. 

8.  The  deep  branch  of  the  ulnar  artery. 

9.  The  superficial  palmar  arch. 
ID.  The  deep  palmar  arch. 

11.  The  digital  branches  of  the  superficial  palmar  arch. 

12.  The  superficialis  volee. 


FIG.  XI. 

1.  The  pisiform. 

2.  The  unciform. 

3.  The  trapezium. 

4.  The  scaphoid  tuberosity. 

5.  The  anterior  annular  ligament. 

6.  6.  The  flexor  longus  pollicis  sheath. 

7.  7.  The  main  flexor  synovial  sheath. 

8.  The  distal  flexor  synovial  sheaths. 

9.  The  continuation  of  the  main  sheath  along  the  little  finger. 


THE    UPPER    EXTREMITY  27 

ment,  and  though  generally  continued  onwards  to  the  end 
Fie  xi.  7     o^  ^^^  little  finger,  the  major  portion  terminates 

^'  ®"  at  the  level  of  the  upper  transverse  crease  of 

the  palm.  The  flexor  tendons  to  the  fore,  middle  and  ring 
fingers  also  possess  more  distally  distinct  synovial  sheaths, 
Fig.  xi.  8     which    extend    from    the    terminal    phalanges 

^'  °'  of   the    fingers    upwards    to  the    necks    of   the 

metacarpal  bones,  a  level  corresponding  roughly  to  the 
lower  transverse  crease  of  the  palm. 

A  distance  of  ^  inch  separates  the  main  synovial  sheath 
above  from  the  more  distal  segments  below. 

On  the  outer  side  of  the  wrist  the  most  marked  feature 
is  the  "  anatomical  snuff-box,"  a  space  bounded  on  the 
radial  side  by  the  tendons  of  the  extensor  ossis  metacarpi 
and  primi  internodii  pollicis  muscles,  and  on  the  ulnar  side 
by  the  tendon  of  the  extensor  secundi  internodii  pollicis. 

In  the  floor  of  the  space  the  styloid  process  of  the  radius 
is  felt,  this  prominence  lying  fully  j  inch  below  the  level 
of  the  corresponding  process  of  the  ulna,  and  also  on  a 
slightly  more  anterior  plane.  Immediately  below  the 
radial  styloid  process  the  scaphoid  bone  lies,  most  pro- 
minent when  the  hand  is  well  adducted.  Below  this,  again, 
the  trapezium  and  the  bases  of  the  first  and  second  meta- 
carpals are  to  be  felt. 

On  the  dorsum  of  the  hand  there  is  a  well-marked 
elevation,  most  noticeable  when  the  wrist  is  fully  flexed, 
due  to  the  projection  of  the  bases  of  the  second  and  third 
metacarpal  bones,  the  styloid  process  of  the  latter  bone 
being  especially  prominent. 

Immediately  above  this  elevation  there  is  a  depression 
where  the  tendons  of  the  extensor  carpi  radialis  longior 
and  brevior  are  felt  as  they  pass  to  their  insertion  into 
the  bases  of  the  second  and  third  metacarpal  bones. 

3 


28  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

Near  the  middle  of  the  posterior  aspect  of  the  lower  end 

of  the  radius  a  tubercle  can  generally  be  dis- 

■'    ■  tinguished,   the   radial   Uihercle,    separating  the 

extensor  secundi  internodii  pollicis  on  the  inner  side  from 

the  tendon  of  the  extensor  carpi  radialis  brevior,  which 

'ies  more  external. 

The  posterior  annular  ligament,  about  f  inch  broad, 
extends  from  the  lower  part  of  the  outer  border 
*  '  of  the  radius  to  the  styloid  process  of  the  ulna 
and  the  carpal  bones  below  the  ulna.  The  ligament  has, 
therefore,  a  downward  and  inward  direction,  and  beneath 
it  pass  the  extensor  tendons.  These  occupy  distinct  com- 
partments, and  possess  synovial  sheaths  as  under  : 

I.  One  compartment  and  synovial  sheath  for  the 
extensor  ossis  metacarpi  and  extensor  primi 
internodii  pollicis. 

2.  One  for  the  extensor  carpi  radialis  longior 
Fig.  xii.,  3.         J  , 

and  brevior. 

3.  One  for  the  extensor  secundi  internodii 
Fig.  xii.,  5.         ,,.    . 

pollicis. 

4.  One  for  the  extensor  communis  digitorum 
Fig.  xii.,  6.          ,  •     T    • 

and  extensor  mdicis. 

Fig.  xii.,  7.       5.  One  for  the  extensor  minimi  digiti. 

6.  One  for  the  extensor  carpi  ulnaris.  The 
Fig.  XII.,  8.  g^|.g^^  Qf  ^]^g  synovial  sheaths  is  indicated  in 
the  diagram,  where  the  radial  artery  is  also  depicted  as  it 
Pior  vi;         crosses    the    "  anatomical    snuff-box  "    towards 

V  Ig.  XII ., 

^' '°-  the  base  of  the  first  interosseous  space,  at 
which  level  the  vessel  dips  down  between  the  two  heads 
of  the  first  dorsal  interosseous  muscle  to  complete  the  deep 
palmar  arch. 


THE  BACK  OF  THE  WRIST 


FIG.  XII. 


I. 

4- 

2,3 


9- 
lo. 


The  posterior  annular  ligament. 
The  rarlial  tubercle. 

5-8.  The  compartments  and  synovial  sheaths  of  the 
extensor  tendons  (see  text). 
The  radial  artery,  crossing  the  "  anatomical  snuff-box." 
The  base  of  the  first  interosseous  space. 

To  face  p. 


the  upper  extremity  2g 

Vessels,  etc.,  of  the  Upper  Extremity. 

The  axillary   artery  extends  from  the  outer    border  of 
the    first    rib    to    the    lower    margin    of    the 

Fig.  vi.,  5. 

teres  major  muscle.     When   the  arm    is   held 

out    at    right  angles  to   the  long  axis  of   the  body,  and 

the   palmar   surface   of    the   hand   turned    upwards,    the 

artery  corresponds  in  direction  to  a  line  drawn  from  the 

middle  of  the  clavicle  to  the  junction  of  the  anterior  and 

middle  thirds  of  the  outer  axillary  wall  at  the  outlet  of 

that  space.     At  its  termination  the  artery  and  the  accom- 

pj     yj  panying   nerves — the   neuro-vascular   bundle — 

10-13.        form  a  projection  which  lies  behind  that  due  to 

the   coraco-brachialis   and   biceps    (short  head)   muscles. 

The  artery  is  divided  into  three  parts  by  the 
Pi  ST.  vi .    4» 

pectoralis  minor  muscle,  which  muscle  can  be 

represented  by  a  triangle,  the  base  corresponding  to  the 

anterior  extremities  of  the  third,  fourth   and  fifth   ribs, 

whilst  the  apex  is  situated  at  the  end  of  the  coracoid  process. 

The  brachial  artery. — The  arm  and  forearm  being  held 

in  the  position  already  indicated  as  necessary 

^      "     'in   order  to    map   out  the    axillary   artery,  the 

brachial  artery  corresponds  to  a  line  drawn  from  the  outer 

wall  of  the  axillary  outlet  at  the  junction  of  its  anterior 

and  middle  thirds  to  the  mid-point  in  front  of  the  bend  of 

the  elbow  at  the  level  of  the  head  of  the  radius. 

'^'  ^'■'        At   the   last    point   the   artery   bifurcates   into 

radial  and  ulnar  arteries. 

The  radial  artery  extends  from  the  middle  of  the  bend 

Fig.  vi.,  17.  ^^  ^^^  elbow  at  the  level  of  the  head  of  the 

radius  to  the  radial  side  of  the  tendon  of  the 

FifiT*  xii. 

9, 10.  '       flexor  carpi  radialis  muscle  just  above  the  base 
of  the  thumb.     The  artery  then  crosses  the  "  anatomical 

3—2 


30  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

snuff-box "    towards    the    base   of    the    first   interosseous 
space. 

The  ulnar  artery  in  the  lower  two-thirds  of  its  course 
accompanies  and  hes  to  the  radial  side  of  the 
ulnar  nerve  (see  "  ulnar  nerve  in  the  forearm,''^ 
p.  32).  The  upper  third  of  its  course  is  represented  by  a 
line  which  passes  obliquely  upwards  and  outwards  to  the 
middle  of  the  bend  of  the  elbow  at  the  level  of  the  head  of 
the  radius. 

The  superficial  palmar  arch  is  formed  by  the  anastomosis 
Fie.  X    7      ^^  ^^^  superficial  division  of  the  ulnar  artery 

9'  '2.  vv'ith  the  superficialis  volse,  or  with  some  other 
branch  of  the  radial  artery.  The  convexity  of  the  arch 
looks  towards  the  fingers,  and  lies  on  a  level  with  the 
lower  border  of  the  outstretched  thumb.  Occasionally 
the  arch  extends  lower  down,  reaching  as  far  as  the  upper 
of  the  two  transverse  creases  on  the  palmar  aspect  of  the 
hand. 

The  deep  palmar  arch,  formed  by  the  anastomosis  of  the 
Fig.  X.  8      radial  artery  with  the  deep  branch  of  the  ulnar, 
^°"         lies  about  one  finger's  breadth  above  the  level 
of  the  superficial  palmar  arch. 

The  digital  branches  of  the  superficial  palmar  arch  pass 

downwards  in  the  intervals  between  the  meta- 

'^"  ^''    '     carpal  bones  to  within   ^  inch  of  the  digital 

clefts,   where    the    vessels    bifurcate    to    run    along    the 

adjacent  sides  of  the  fingers. 

The  circumflex  nerve  and  the  posterior  circumflex  artery 
pj  j(jjj__  3_  both  pass  backwards  through  the  quadrilateral 
Fig.  VI.,  7.  muscular  space,  and  curl  round  the  surgical 
neck  of  the  humerus  towards  the  outer  and  front  aspect 
of  the  shoulder  region.  The  artery  anastomoses  with  the 
anterior  circumflex  artery,  and  the  level  of  the  arterial 


< 

w 
p^ 
o 

fa 

c 
z 


a 


u 

-^ 

» 

a 


«      2 


!-  .^  <U 


^  o 

2 

S  '^ 

<u    . 

"H.S 

ti  !^ 

cy. 

•"  u 

u  a; 

^.2 

O  S 

7^  "^ 

o  aj 

^ 

u  oj 

i£     X 

:;  0 

rt 

0  c5 

\6  i^x  d  o 


.  5  "oj  o 

ij  o  >  a;  T^ 

i-  y  ^  "  ^ 

n  n  1*  -H 


cB  cs  o  -S  aj 

1»    1>    <U    UJ    c^ 

H  H  H  ?  H 


■-   N   rO  "^  "O 


THE  SHOULDER  AND  ARM 


FIG.  XIV. 

1.  The  clavicle. 

2.  The  acromion  process. 

3.  The  external  condyle  of  the  humerus. 

4.  4.  Hamilton's  line. 

5.  The  deltoid  muscle. 

6.  6.  The  musculo-spiral  nerve. 


To  face  p.  31. 


THE    UPPER    EXTREMITY  3I 

circle  so  formed,  and  of  the  posterior  circumflex  nerve, 
may  be  represented  by  a  line  drawn  at  right  angles  to  the 
shaft  of  the  humerus  from  a  point  just  above  the  centre 
of  the  deltoid  muscle. 

The  miisculo-cutancous  nerve  usually  pierces  the  inner 
aspect  of  the  coraco-brachialis  muscle  about  i  to  2  inches 
below  the  coracoid  process.  It  then  runs  downwards  and 
outwards,  deep  to  the  biceps  muscle,  towards  the  outei 
bicipital  sulcus,  at  which  level  it  becomes  cutaneous. 
The  course  of  the  nerve  in  the  arm  can,  therefore,  be 
roughly  indicated  by  a  line  from  the  coracoid  process 
above  to  the  outer  bicipital  sulcus  below. 

The  mtisculo-spiral  nerve,  accompanied  by  the  anterior 
branch  of  the  superior  profunda  artery,  pierces 
Fig.  xiv.  6,  the  external  intermuscular  septum  of  the  arm, 
from  behind  forwards,  at  the  junction  of  the 
upper  and  middle  thirds  of  a  line  drawn  from  the  insertion 
of  the  deltoid  muscle  to  the  external  condyle  of  the 
humerus.  Below  this  point  the  nerve  passes  downwards 
and  inwards  to  the  outer  bicipital  sulcus,  where  it  bifurcates 
into  its  two  terminal  branches.  Above  the  point  at  which 
the  nerve  pierces  the  external  intermuscular  septum,  the 
course  of  the  nerve  may  be  represented  by  a  curved  line 
drawn  upwards  and  inwards  to  the  junction  of  the  upper 
arm  with  the  posterior  fold  of  the  axilla. 

The  radial  nerve,  a  branch  of  the  musculo-spiral,  arises 
Fig.  vi.,  16  ^^  the  outer  bicipital  sulcus,  and  passes  vertically 
ig.  XIII.,  '0(jown  the  forearm,  accompanying,  and  lying  to 
the  outer  side  of,  the  radial  artery  in  its  middle  third. 
At  the  junction  of  the  middle  and  lower  thirds  of  the  fore- 
arm, the  nerve  turns  round  the  outer  border  of  the  radius 
under  cover  of  the  supinator  longus  tendon,  to  be  dis- 
tributed to  the  back  of  the  wrist  and  hand. 


32  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

The  posterior  interosseous  nerve  arises  from  the  musculo- 

r--  •••  n  spiral  in  the  outer  bicipital  sulcus,  and  curls 
Fig.  XIII.,  9.     ^  r  ' 

round  the  neck  of  the  radius  in  the  substance 
of  the  supinator  brevis  muscle,  emerging  from  the  posterior 
border  of  that  muscle  2  inches  below  the  head  of  the 
radius.  It  then  passes  vertically  down  the  posterior  aspect 
of  the  forearm,  lying  about  midway  between  the  inner  and 
outer  borders,  and  terminating  in  a  gangliform  enlarge- 
ment at  the  posterior  aspect  of  the  wrist. 

The  median  nerve  in  the  arm. — This  nerve  accompanies 
Fig  vi    11     t^^   brachial  artery,  and  therefore   presents   a 
similar  surface  marking.     It  is  necessary,  how- 
ever, to  bear  in  mind  that  the  nerve  crosses  the  artery  super- 
ficially from  above  downwards  and  from  without  inwards. 
The  median  nerve  in  the  forearm  passes  vertically  down- 
wards from  the   inner  bicipital   sulcus  to  the 
front  of  the  wrist,  there  lying  to  the  ulnar  side 
of  the  flexor  carpi  radialis  and  under  cover  of  the  palmaris 
longus  tendon.     The  nerve  then  passes  under  the  anterior 
annular  ligament  to  the  palm. 

The  ulnar  nerve  in  the  upper  third  of  the  arm  lies  along 

the  inner  side  of  the  brachial  artery.    It  then 

'^'  ^'■'     ■  leaves   that   vessel,  and,   accompanied   by   the 

inferior  profunda  artery,  passes  downwards  and  backwards 

to  reach  the  hollow  between  the  internal  condyle  and  the 

olecranon  process. 

The  ulnar  nerve  in  the  forearm  corresponds  in  direction 

to  a  line  drawn  from  the  internal  condyle  of  the 

'g-  VI.,      .  ]^^j_^gj-^g  ^Q  ^]^g  radial  side  of  the  pisiform  bone. 

In  front  of  the  wrist  the  nerve  lies  to  the  radial  side  of 
the  tendon  of  the  flexor  carpi  ulnaris  muscle,  and  subse- 
quently passes  superficial  to  the  anterior  annular  ligament 
to  its  palmar  distribution. 


THE    UPPER   EXTREMITY  33 

The  palmar  fascia  is  triangular  in  shape,  the  apex  being 
attached  to  the  anterior  annular  ligament  between  the 
thenar  and  hypothenar  eminences,  whilst  the  base  corre- 
sponds to  the  proximal  ends  of  the  four  inner  fingers. 

The  Creases  of  the  Palm  and  Fingers. 

The  upper  transverse  crease  on  the  palmar  aspect  of 
the  hand  lies  just  below  the  normal  limit  of  the  superficial 
palmar  arch,  but  at  the  level  of  the  lower  limit  of  the 
main  flexor  synovial  sheath.  The  lower  crease  crosses 
the  necks  of  the  metacarpal  bones,  and  corresponds  to 
the  upper  limit  of  the  distal  flexor  synovial  sheaths. 

The  metacarpo-phalangeal  joints  lie  about  half-way 
between  the  distal  crease  of  the  palm  and  the  proximal 
crease  of  the  fingers.  The  middle  and  distal  creases 
on  the  palmar  aspect  of  the  fingers  correspond  fairly 
accurately  to  the  respective  interphalangeal  joints.  The 
"  knuckles "  are  formed  by  the  heads  of  metacarpal 
bones. 


CHAPTER    III 
THE   THORAX 

The  majority  of  the  thoracic  viscera  are  depicted  on  the 
surface  in  relation  to  the  costal  cartilages,  ribs  and  inter- 
costal spaces,  and  it  is  therefore  necessary  to  lay  stress  on 
certain  important  points : 

1.  That  the  twelve  ribs  are  divided  into  two  groups  : 
{a)  True  ribs,  seven  in  number,  articulating  by  means  of 
their  costal  cartilages  with  the  mesial  sterno-xiphoid  bone  ; 
(b)  False  ribs,  five  in  number,  all  falling  short  of  the  middle 
line,  the  upper  three  attached  to  the  costal  cartilage  of  the 
rib  above,  the  lower  two  not  articulating  with  the  trans- 
verse process  of  the  corresponding  vertebra,  and  the 
anterior  extremities  not  attached  to  the  costal  cartilage 
of  the  rib  above.  These  last  two  ribs  are  therefore  known 
as  "  floating  ribs." 

2.  That   the   first   rib   lies    mainly  under  cover  of   the 

clavicle,  but  that  its  costal  cartilage  can  gener- 
ig.  111.,      .  ^jj^  ^^  palpated  with  ease  as  it  lies  below  the 

sternal  end  of  the  clavicle. 

3.  That  the  first  interspace  which  can  be  felt  to  the 
outer  side  of  the  sternum  is  the  first  interspace.  This 
axiom  may  appear  at  first  sight  to  be  quite  unnecessary, 
but  it  is  in  reality  not  uncommon  for  students  to  regard 
the  first  space  which  can  be  felt  as  the  second  interspace. 

34 


THE    THORAX 


35 


4.  That  the  second  costal  cartilage  articulates  in  front 
Fig.  iii..        at  the  angle  of  Ludwig  with  the  adjoining  parts 

of  the  manubrium  and  gladiolus. 

5.  That  the   seventh  costal   cartilage   articulates  with 

the  adjoining  parts  of  the  gladiolus  and  xiphoid 
cartilage. 

6.  That   the    anterior    extremity    of    the    ninth    costal 

cartilage    corresponds    almost    exactly    to    the 

PifiT.   XX. 

point    where    the    linea    semilunaris    cuts    the 
costal  arch. 

7.  That  the  twelfth  rib  is  liable  to  great  variation  in 
size,  frequently  being  so  insignificant  that  it  cannot  be 
felt  at  all.  It  is,  therefore,  often  advisable  to  count  from 
above  in  fixing  any  particular  rib. 

8.  That  the  intercostal  spaces,  in  consequence  of  the 
downward  and  forward  obliquity  of  the  ribs,  are  wider  in 
front  than  behind. 

The  female  mamma,  when  well  developed,  extends  up- 
wards to  the  second  rib,  inwards  to  the  outer  border  of 
the  sternum,  downwards  to  the  sixth  or  seventh  rib,  and 
outwards  to  the  mid-axillary  line.  The  true  glandular 
substance  is,  however,  less  regular  in  disposition,  pro- 
longations passing  in  various  directions.  Of  these,  the 
most  important  is  the  so-called  "  axillary  prolongation," 
which  is  directed  upwards  and  outwards  along  the  anterior 
fold  of  the  axilla. 

The  nipple  usually  corresponds  to  the  fourth  mterspace 

It  is  variable  in  position,  and  not  infrequently 

'^'  ^'^'        overlies  the  fourth  rib.     In  the  female  the  nipple 

lies  just  below,  and  external  to,  the  apex  or  central  point 

of  the  breast. 

Fig  XV  The  heart  lies  opposite  the  middle  four  dorsal 

''^-  vertebrae,    and    the    projection    of    its    anterior 


36  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

surface  upon  the  front  of  the  chest  wall  may  be  indicated 
in  the  following  manner. 

Take  the  following  four  points  : 

1.  The  lower  border  of  the  second  left  costal  cartilage 
about  I  inch  from  the  left  border  of  the  sternum. 

2.  The  upper  border  of  the  third  right  costal  cartilage 
^  to  I  inch  from  the  right  border  of  the  sternum. 

3.  The  lower  border  of  the  sixth  right  costal  cartilage 
f  inch  from  the  right  border  of  the  sternum. 

4.  The  fifth  left  interspace  i^-  inches  below  and  just 
internal  to  a  line  drawn  vertically  downwards  from  the 
nipple.  If  any  abnormality  exists  with  regard  to  the 
position  of  the  nipple,  this  last  point  may  be  fixed  with 
greater  accuracy  by  taking  a  point  in  the  fifth  left  inter- 
space nearly  4  inches  from  the  middle  line. 

The  apex  beat — the  point  of  maximum  impulse  of  the 
left  ventricle  against  the  chest  wall — lies  in  the 
'  '  fifth  left  interspace  I5  inches  below  and  ^  inch 
internal  to  the  nipple,  or  3J  inches  from  the  middle  line. 
The  position  of  the  apex  beat,  therefore,  does  not  exactly 
represent  the  outermost  limit  of  the  left  ventricle.  The 
above  four  points  should  now  be  joined  in  the  following 
manner  : 

Points  I  and  2  by  a  straight  line. 

Points  2  and  3  by  a  curved  line,  the  heart  reaching 
the  greatest  distance  from  the  middle  line,  I5-  inches,  in 
the  fourth  interspace. 

Points  3  and  4  by  a  line  presenting  a  slight  downward 
convexity,  and  cutting  across  the  middle  line  in  close 
relation  to  the  xiphisternal  junction. 

Points  I  and  4  by  a  line  presenting  a  fairly  well  marked 
convexity  to  the  left.  In  the  illustration  this  line  is 
drawn  rather  too  straight. 


FIG.  XV. 

N.B. — 111  this  and  in  other  figures  in  which  the  costal  cartilages  are 
depicted  the  numbered  references  do  7iot  refer  to  the  corresponding 
cartilages.     These  are  numbered  for  general  convenience  only. 
1-4.  The  four  points  of  the  heart. 

5.  The  auricular  area. 

6.  The  ventricular  area. 

7.  The  left  ventricle. 

8.  The  apex  beat. 

9.  The  pulmonary  valve. 

10.  The  pulmonary  artery. 

11.  The  aortic  valve. 
V2.  The  mitral  valve. 

13.  The  tricuspid  valve. 

14.  The  ascending  aorta. 

15.  The  aortic  arch. 

16.  The  innominate  artery. 

17.  The  right  and  left  common  carotid  arteries. 

18.  The  right  and  left  subclavian  arteries. 

19.  The  right  and  left  subclavian  veins. 

20.  The  right  and  left  internal  jugular  veins. 

21.  The  right  and  left  innominate  veins. 

22.  The  superior  vena  cava. 

23.  The  inferior  vena  cava. 

24.  The  abdominal  aorta. 

25.  The  cceliac  axis. 

26.  The  superior  mesenteric  artery. 

27.  The  renal  arteries. 

28.  The  inferior  mesenteric  artery. 

29.  The  common  iliac  arteries. 

30.  The  internal  iliac  arteries. 

31.  The  external  iliac  arteries. 

32.  The  kidney. 

33.  The  ureters. 

34.  The  ovary. 


THE  HEART,  GREAT  VESSELS,  KIDNEY,  AKD 
URETER 


FIG,  XV. 


To  Jace  p,  36. 


THE    THORAX  37 

A  line  joining  Points  i  and  3  divides  this  cardiac  area 

into    two    parts,  which   roughly  correspond  to 

the  aurictdar  area  above  and  to  the  right,  and 

the  ventricular  area  below  and  to  the  left.  This 
RifiT,  XV.   6. 

ventricular    area    is    occupied    mainly    by   the 

right    ventricle,   whilst    a    narrow    strip    along 
ig.  XV.,    .    ^^^  j^^^  border  represents  that  part  of  the  left 
ventricle  which  comes  to  the  surface. 

The  four  points  given  above  for  marking  out  the  pro- 
jection of  the  heart  on  the  anterior  thoracic  wall  may  be 
simplified  by  taking  and  joining  the  following  four  points  : 

1.  The  upper  border  of  the  third  right  chondro-sternal 
junction. 

2.  The  lower  border  of  the  second  left  chondro-sternal 
junction. 

3.  The  lower  border  of  the  sixth  right  chondro-sternal 
junction. 

4.  The  position  of  the  apex  beat. 

By  uniting  these  four  points,  the  heart  is  mapped  out 
for  most  practical  purposes  with  sufiicient  accuracy. 

The  Valves  of  the  Heart. 

1.  The  pulmonary  valve  is  situated  at  the  highest  level, 

and  lies  opposite  the  upper  border  of  the  third 
Fig.  XV.,  9.  j^£^  costal  cartilage,  close  to  its  junction  with 
the  sternum. 

2.  The  aortic  valve  lies  just  below  and  internal  to  the 

pulmonary  valve  at  the  lower  border  of  the 
Fig.  XV.,  II.   ^j^.^^  ^^^^  costal  cartilage  at  its  junction  with 

the  sternum. 

3.  The  mitral  or  left  auriculo- ventricular  valve  is  situated 

behind  the  left  half  of  the  sternum  at  the  level 
Fig.  XV.,  12.  ^^  ^^^  fourth  chondro-sternal  junction. 


38  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

4.  The  tricuspid  or  right  auriculo-ventricular  valve  Hes 
Fig.  XV.,  very  obhquely  behind  the  sternum  at  the  level 
of  the  fourth  interspace  and  the  anterior  extremi- 
ties of  the  fifth  costal  cartilages,  extending  downwards  and 
to  the  right  almost  as  far  as  the  sixth  chondro-sternal 
junction. 

The  Aorta  and  other  Vessels,  etc. 

The  ascending  aorta,  2  to  2^  inches  long,  arises  behind 

Fig.  XV.,       the  left  border  of  the  sternum  at  the  level  of 

the  third  costal  cartilage,  and  passes  upwards 

and  to  the  right  towards  the  right  border  of  the  sternum 

at  the  level  of  the  second  costal  cartilage. 

The  aortic  arch  is  directed  backwards  and  to  the  left, 
Fig.  XV.,  the  upper  limit  lying  about  i  inch  below  the 
suprasternal  notch,  or  half-way  between  that 
notch  and  the  angle  of  Ludwig.  The  arch  becomes  the 
descending  aorta  at  the  left  side  of  the  lower  part  of  the 
body  of  the  fourth  dorsal  vertebra. 

The  descending  thoracic  aorta,  7  to  8  inches  long,  passes 
onwards  through  the  posterior  mediastinum,  and  pierces 
the  diaphragm  at  the  level  of  the  twelfth  dorsal  vertebra. 
The  site  of  diaphragmatic  perforation  is  represented  on  the 
surface  by  a  point  situated  just  to  the  left  of  the  middle 
line,  two  fingers'  breadth  above  the  transpyloric  plane.* 

The  innominate  artery,  ij  to  2  inches  long,  arises  from 
Fig.  XV.        the  aortic  arch  in  the  middle  line  i  inch  below 

^^"  the  suprasternal  notch,  and  passes  upwards  and 

to  the  right  to  the  right  sterno-clavicular  articulation,  at 
which  level  it  bifurcates  into  its  two  terminal  branches. 

The  left  common  carotid  (thoracic   course)  arises  from 

*  Any  "planes"  mentioned  in  this  chapter  will  be  explained  in  the 
chapter  on  the  abdomen. 


THE   THORAX  39 

the  aortic  arch  on  a  posterior  plane  to,  and  slightly  to 
Fig.  XV.,  th^  ^sft  of,  the  trunk  of  the  innominate  artery, 
and  passes  upwards  and  to  the  left  to  the  left 
sterno-clavicular  articulation. 

The  left  subclavian  artery  (thoracic  course)  arises  from 
Fig.  XV.,        ^^^   aortic   arch   on   a   posterior  plane  to,  and 

^^-  slightly  to  the  left  of,  the  thoracic  part  of  the 

left  common  carotid  artery,  and  passes  almost  vertically 
upwards  behind  the  left  border  of  the  sternum  to  the  left 
sterno-clavicular  joint. 

The  superior  mediastinum  is  bounded  above  by  the  plane 

of  the  thoracic  inlet  and  below  by  a  plane  which 

passes  backwards  from  the  angle  of  Ludwig  in 

front  to  the  lower  border  of  the  fourth  dorsal  vertebra 

behind  (Ludwig's  plane). 

The  pulmonary  artery  arises  opposite  the  upper  border 
pj     j^y         of  the  third  left  costal  cartilage  at  its  junction 

'°-  with  the  sternum,  and  passes  backwards  and 

slightly  upwards  to  its  bifurcation,  which  takes  place 
opposite  the  second  left  costal  cartilage. 

The  internal  mammary  artery  arises  from  the  first  part 
of  the  cervical  course  of  the  subclavian 
ig.  XX.,  .  g^j-^gj-y^  ^^^  passes  almost  vertically  downwards 
behind  the  corresponding  sterno-clavicular  joint.  In  its 
further  thoracic  course,  the  artery  lies  ^  inch  external 
to  the  outer  border  of  the  sternum,  bifurcating  opposite 
Fig.  XX.,       the  sixth  costal  cartilage  or  the  sixth  interspace 

®' '°-  into  the  musculo-phrenic  and  superior  epigastric 
arteries.  The  former  vessel  curves  outwards,  following  the 
line  of  the  costal  arch,  whilst  the  latter  passes  onwards  to 
enter  the  sheath  of  the  rectus  abdominis  muscle. 

The  left  innominate  vein,  3  inches  long,  is  formed 
opposite  the  left  sterno-clavicular  joint,  and  passes  to  the 


40  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

right,  slightly  overlapping  the   upper   part  of  the   aortic 
Fig.  XV.         arch,   and  occupying   the    greater    part   of   the 
space  between  the  summit  of  the  arch  below 
and  the  suprasternal  notch  above. 

The  right  innominate  vein  is  formed  at  the  right  sterno- 
Fig.  XV ,        clavicular   joint,   and    passes    obliquely   down- 

21 

wards  and  inwards  to  meet  the  corresponding 
vein  of  the  opposite  side  at  the  lower  border  of  the  first 
right  costal  cartilage  close  to  its  junction  with  the  sternum. 

The  superior  vena  cava,  formed  by  the  junction  of  the 
'  Fig.  XV.,        above  two  veins,  is  directed  almost  vertically 

^^'  downwards  from  the  lower  border  of  the  first 

right  costal  cartilage  close  to  its  junction  with  the 
sternum,  to  open  into  the  right  auricle  of  the  heart  at  the 
level  of  the  upper  border  of  the  third  right  chondro- 
sternal  junction. 

The  inferior  vena  cava  enters  upon  its  short  intrathoracic 
Fig.  XV.,       course  by  passing  through  the  quadrate  opening 

^"^"  of   the  diaphragm   at  the  level  of   the  eighth 

dorsal  vertebra,  opening  into  the  right  auricle  of  the  heart 
opposite  the  fifth  right  interspace  and  the  adjoining  part 
of  the  sternum. 

The  vena  azygos  major  drains  the  whole  thoracic  wall, 
except  the  first  space  on  the  right  side  and  the  upper  three 
spaces  on  the  left.  It  opens  into  the  superior  vena  cava 
at  the  level  of  the  lower  part  of  the  second  right  inter- 
space, curling  round  the  root  of  the  right  lung  in  order  to 
reach  its  destination. 

The  main  aortic  intercostal  vessels  occupy  the  subcostal 
groove  of  a  rib  as  they  pass  round  the  chest  wall,  lying 
between  the  corresponding  vein  above  and  the  nerve 
below. 


the  thorax  4i 

The  Pleura  and  Lungs. 

I.  The  pleural  sacs. — When  the  shoulders  are  depressed, 

Fig.  xvi.,  5.  the  two  clavicles  lie  practically  at  right  angles 

ig.  XVII.,  4.  ^Q  ^]^g  j^j^g  g^j^-g  q£  ^]^g  body,  and  in  this  position 

the  apices  of  the  pleural  sacs  extend  into  the  supra- 
clavicular region,  lying  about  i^  inches  above  the  clavicle 
under  cover  of  the  clavicular  head  of  the  sterno-cleido- 
mastoid  muscle. 

The  anterior  margin  of  each  sac  sweeps  downwards  and 
inwards  behind  the  corresponding  sterno-clavicular  joint, 
the  two  sacs  converging  towards  the  angle  of  Ludwig,  at 
which  level  they  meet  one  another  just  to  the  left  of  the 
middle  line.  They  then  pass  vertically  downwards  parallel 
to  one  another  as  far  as  the  level  of  the  fourth  chondro- 
sternal  junction. 

The  right  sac  passes  onwards  in  the  same  straight  line 
to  the  sixth  or  seventh  chondro-sternal  articulation,  and 
then  sweeps  round  the  anterior,  lateral,  and  posterior 
aspects  of  the  chest  wall,  cutting  across — 

(i)  The  upper  part  of  the  eighth  costal  cartilage  in  the 
lateral  vertical  line ; 

(2)  The  tenth  rib  in  the  mid-axillary  line  ; 

(3)  The  eleventh  rib  in  the  line  of  the  inferior  angle  of 
the  scapula ; 

(4)  The  twelfth  rib  at  the  outer  border  of  the  erector 
spinae  muscle. 

The  obliquity  of  the  twelfth  rib  causes  the  pleura  to  fall 
below  the  level  of  the  inner  half  of  the  rib,  the  pleura 
in  this  last  part  of  its  course  being  directed  inwards 
towards  the  spine  of  the  twelfth  dorsal  vertebra. 

The  left  pleura,  from  the  level  of  the  fourth  left  chondro- 
sternal  articulation,  sweeps  obliquely  outwards  and  down- 

4 


42  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

wards  behind  the  costal  cartilages  of  the  fifth,  sixth  and 
seventh  ribs  to  the  eighth  costal  cartilage  in  the  lateral 
vertical  plane.  Beyond  this  point  the  left  pleura  follows 
the  same  general  direction  as  the  right  sac,  descending, 
however,  to  a  slightly  lower  level. 

The  lowest  limit  reached  by  the  two  pleural  sacs  is 
situated  in  the  mid-axillary  line,  the  sacs  there  cutting 
across  the  tenth  rib  about  2  inches  above  the  costal 
margin,  which  is  in  this  situation  usually  represented  by 
the  tip  of  the  eleventh  rib. 

Difficulty  is  sometimes  experienced  in  endeavouring  to 
verify  the  position  of  the  twelfth  dorsal  spine,  and  in  such 
cases  the  pleural  reflection  behind  the  mid-axillary  region 
may  be  represented  by  a  line  which  passes  almost  trans- 
versely backwards  toward  the  median  posterior  line  from 
the  tenth  rib  in  the  mid-axillary  line. 

The  two  sacs  are  for  the  most  part  separated  from  one 

another  by  the  width  of  the  vertebral  bodies — 

"    *  about    i|    inches.     In   the   lower   part   of   the 

posterior  mediastinum,  however,  the  right  sac  approaches 

the  median  line. 

2.  The  lungs  may  be  mapped  out  in  part  by  lines  similar 

to  those   given  for  the  pleural  sacs.     The   apex  of   the 

■    R   upper  lobe  of  each  lung  extends  into  the  supra- 

Fig.  xvii.,     clavicular    region,    and    the    anterior    margins 
5. 

converge  towards  the  angle  of  Ludwig,  cutting 

obliquely  across  the  corresponding  stern o-clavicular  joint. 

The  two  anterior  borders  do  not,  however,  meet  at  the 

angle  of  Ludwig,  for  the  right  lung  on  reaching  the  middle 

line  passes  vertically  downwards  as  far  as  the  level  of  the 

sixth  or  seventh  chondro-sternal  junction,  whilst  the  left 

lung  runs  down  behind  the  left  border  of  the  sternum  to 

the  junction  of  the  fourth  costal  cartilage  with  the  sternum. 


THE  PLEURAL  SACS,  LUNGS,  ETC. 


FIG.  XVI I, 


1,  I.  The  spinal  dural  sheath. 

2,  The  spinal  cord. 

3,  The  filiun  tenninale. 

4,  4.  The  pleune. 

5,  5.  The  lunj^s. 

6,  6.  The  main  oblique  fissures  of 

the  lunj^s. 

7,  7.  The  apex  of  the  lower  lobe 

of  the  lunjis. 

8,  8.  The  roots  of  the  lun;<s, 

»  The  transvcTse  processes  of  .l.e  first  and  second  lun.bar  vertebra:  should  be  dr.wu  in  such 
.-I  manner  as  to  come  into  contact  with  the  inner  border  oi  the  kidney.  To/ace  p.  42 


The  spleen. 

The  left   kiilney    in   Morris's 

quadrilateral.* 
The  ureter. 
The  liver. 

The  descending  colon. 
The  rectum. 
The   posterior    superior    diac 

spine. 


THE    THORAX  43 

The  right  lung,  from   the  level  of  the  sixth  or  seventh 
chondro-sternal  junction,  sweeps  outwards,  cutting  across — 
(i)  The  sixth  costal  cartilage  in  the  lateral  vertical  line 

(2)  The  eighth  rib  in  the  mid-axillary  line ; 

(3)  The  tenth  rib  in  the  line  of  the  inferior  angle  of  the 
scapula,  and  finally  passing  inwards  towards  the  tenth 
dorsal  spine. 

The  left  lung,  from  the  outer  border  of  the  sternum  at 
the  level  of  the  fourth  chondro-sternal  articulation,  passes 
outwards  for  a  short  distance  along  the  lower  border  of  the 
fourth  costal  cartilage,  and  then  turns  downwards  and 
inwards  in  a  curved  direction  to  the  sixth  costal  cartilage 
in  the  lateral  vertical  plane.  The  lung  then  sweeps  round 
the  chest  wall,  following  a  course  similar  to  that  already 
indicated  as  pursued  by  the  right  lung,  the  left  lung  lying, 
however,  at  a  slightly  lower  level. 

Stress  should,  perhaps,  be  laid  on  the  fact  that,  as  the 
lower  border  of  each  lung  sweeps  round  the  antero-lateral, 
lateral,  and  posterior  aspects  of  the  chest  wall,  from  the 
sixth  costal  cartilage  in  front  to  the  tenth  dorsal  spine 
behind,  the  course  pursued  is  practically  transverse  to  the 
long  axis  of  the  body. 

It  will  be  convenient  to  here  put  in  a  tabulated  manner 
the  comparative  lower  levels  of  the  right  pleura  and  lung. 
Starting  in  each  case  at  the  right  chondro-sternal  junction, 
the  pleura  and  lung  may  be  represented  by  lines  which 
traverse  the  chest  wall,  cutting  across  the 

(i)  Lateral  vertical  line  at  the  eighth  costal  cartilage 
(pleura) — sixth  costal  cartilage  (lung). 

(2)  Mid-axillary  line  at  the  tenth  rib  (pleura)— eighth 

rib  (lung). 

(3)  Scapular  line  at  the  eleventh  rib  (pleura)— tenth 

rib  (lung). 

4—2 


44  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

(4)  And  sweeping  in  towards  the  twelfth  dorsal  spine 
(pleura) — tenth  dorsal  spine  (lung). 
The  numbers  to  be  remembered  are,  therefore,  6,  8,  10, 
II,  and  12  for  the  pleura,  and  6,  6,  8,  10,  10  for  the  lung. 

On  the  left  side,  the  levels  are  similar  with  two  main 
exceptions — {a)  the  lung  and  pleura  sweep  outwards  so  as 
to  leave  a  part  of  the  heart  uncovered  (see  "  superficial 
cardiac  dulness"),  {b)  both  lung  and  pleura  descend  to  a 
slightly  lower  level. 

The  Lower  Limit  of  the  Lung,  the  Pleura,  and  the  Liver 
in  the  Right  Mid-axillary  Line. 

(i)  The  lung  corresponds  to  the  eighth  rib. 

(2)  „     pleura  „  „  tenth  rib. 

(3)  „     liver  ,,  „  costal  margin,  or  even 

lower. 

The  fissures  of  the  lungs. — The  main  fissure  of  each  lung 
Fie.  xvi.  7.  ^^  indicated  by  a  carved  line  which  starts  behind 
Fig.  XVII.,  6.  ^^  the  level  of  the  second  dorsal  spine,  the  apex 
of  the  main  lower  lobe  of  each  lung,  therefore,  being 
situated  immediately  below  and  external  to  this  dorsal 
spine.  When  the  arms  fall  naturally  to  the  side  of  the 
body,  the  line  representing  the  main  fissure  cuts  across  the 
infraspinous  surface  of  the  scapula,  and  crossing  then  the 
fifth  rib  in  the  mid-axillary  line,  terminates  in  front  at 
the  inferior  border  of  the  lung  at  the  level  of  the  sixth 
chondro-costal  junction.  When  the  arms  are  extended 
above  the  head,  the  inferior  angle  of  the  scapula  slides 
upwards  and  outwards  on  the  chest  wall.  In  this  position 
the  main  fissure  is  represented  by  a  line  from  the  second 
dorsal  spine  which  passes  downwards  and  outwards  to  the 
inferior  angle  of  the  scapula,  and  then  forwards  to  the 
termination  of  the  fissure  at  the  inferior  border  of  the  lung. 


THE    THORAX 


45 


The  smaller  or  upper  fissure  of  the  right  lung  separates 

off  from  the  main  fissure  in  the  mid-axillary  line,  and  passes 

almost  transversely  forwards  alone:  the  lower 
Fig.  XVI.,  8.  J  b 

border  of  the  fourth  rib  and  costal  cartilage  to 

the  anterior  border  of  the  lung.     It  is  thus  manifest  that 

the  anterior  aspect  of  the  chest,  above  the  level  of  the  sixth 

costal  cartilage,  corresponds  to  the  upper  two  lobes  of  the 

right  lung  and  to  the  upper  lobe  of  the  left  lung,  whilst 

the  posterior  aspect  of  the  chest  below  the  level  of  the 

second  dorsal  spine  corresponds  to  the  right  and  left  main 

lower  lobes. 

The  apices  of  the  upper  and  lower  lobes. — It  will  be  here 
in  place  to  again  lay  stress  on  the  fact  that  the  apex  of  the 
upper  main  lobe  lies  about  i  inch  above  the  clavicle  in  the 
supraclavicular  fossa,  under  cover  of  the  clavicular  head 
of  a  well-developed  sterno-cleido-mastoid  muscle,  and 
Fie  xvi.  ^hat  the  apex  of  the  lower  lobe  lies  immediately 
Fig.  XVII.,  7.  |-)giQ^  ^j^(j  external  to  the  spine  of  the  second 
dorsal  vertebra. 

The  roots  of  the  lungs  lie  opposite  the  spines  of  the  fourth, 
fifth,  and  sixth  dorsal  vertebrae,  and  the  bodies 

PifiT.  xvii,    8. 

'of  the  fifth,  sixth,  and  seventh  vertebrae.  They 
may  be  so  represented,  lying  also  midway  between  the 
median  posterior  line  and  the  vertebral  border  of  the 
scapula,  the  arms  hanging  loosely  from  the  shoulders. 

The    areas    of   deep    and    superficial    cardiac    dulness. — 

I.  The   area  of   deep    cardiac    dulness,    quadrate    in    form. 

Fig.  XV.,       corresponds     to    the     complete    area    already 

mapped  out  as  representing  the  projection  of 

the  heart  on  to  the  anterior  aspect  of  the  chest  wall. 

2.  The  area  of  superficial  cardiac  dulness,  more  or  less 
triangular  in  shape,  corresponds  to  that  part  of  the  heart 
which  is  not  covered  by  the  thin  anterior  margin  of  the 


46  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

lung.  This  area  can,  with  sufficient  accuracy,  be  defined 
pj  j^yj  ^0  3-S  a  triangular  space,  the  left  border  being 
Fig.  XV.  formed  by  a  line  from  the  fourth  left  chondro- 

sternal  articulation  to  the  apex  beat  of  the  heart  in 
the  fifth  left  interspace,  the  right  border  by  a  line  which 
passes  downwards  along  the  middle  of  the  sternum  from  the 
level  of  the  anterior  extremities  of  the  fourth  to  the  seventh 
costal  cartilages,  and  the  base  by  a  line  which  passes  out- 
wards from  the  level  of  the  seventh  costal  cartilage  to  the 
position  of  the  apex  beat. 

A  reference  to  Figs.  xiv.  and  xv.  will  make  it  evident 
thai  paracentesis  of  the  pericardium  can  be  performed,  without 
injury  to  pleura  or  lung,  in  the  fifth  left  intercostal  space. 
The  internal  mammary  artery  runs  vertically  downwards 
about  I  inch  from  the  outer  border  of  the  sternum,  and 
the  needle  should,  therefore,  be  inserted  through  the  fifth 
intercostal  space  about  i  inch  from  the  outer  border 
of  the  sternum. 

The  trachea  and  bronchi. — The  trachea,  4I-  inches  long, 

commences     immediately    below    the    cricoid 
Fig.  xvi.,  1.  . 

cartilage,    on   a    level  with   the  sixth   cervical 

vertebra,  and  passing  downwards   through   the   superior 

mediastinum,  bifurcates  opposite  the  level  of  the  lower  part 

of  the  bod}^  of  the  fourth  dorsal  vertebra  (Ludwig's  plane). 

The   two   bronchi   diverge,   the   left   being   the  longer 

Fig.  xvi.,  2,   ^^"^  ^hs    narrower.     The  tendency  of  foreign 

'  bodies  to  pass  more  frequently  into  the  right 

bronchus  is  explained  by  the  fact  that  the  septum  between 

the  two  bronchi  is  placed  to  the  left  of  the  middle  line  of 

the  trachea.     The  right  bronchus,  previous  to  the  giving- 

off  of  the  eparterial  bronchus,  is  less  obliquely  inclined 

than   the   left  bronchus,   though  subsequently  it  follows 

much  the  same  course. 


THE    THORAX  47 

The  greater  obliquity  of  the  left  bronchus  accounts  also 
for  the  fact  that  the  left  pulmonary  artery  tends  to  lie  at 
the  higher  level,  whilst  the  right  pulmonary  artery  lies 
below  the  level  of  the  corresponding  bronchus. 

The  oesophagus,  9  inches  long,  also  commences  at  the 
Fig.  xix.,       level    of    the    cricoid    cartilage,    and    passing 

''  ^'  downwards  through  the  superior  and  posterior 

mediastina,  pierces  the  diaphragm  at  the  level  of  the 
tenth  dorsal  vertebra,  entering  the  stomach  at  the  level 
of  the  eleventh  vertebra. 

The  entrance  of  the  oesophagus  into  the  stomach  may 
be  indicated  by  taking  a  point  on  the  seventh  left  costal 
cartilage  f  inch  away  from  the  left  side  of  the  xiphisternal 
junction. 

The  thoracic   duct,    15    to    18   inches   long,  commences 

as  the  receptaculum  chyli,  a  spindle-shaped  sac  which  lies 

opposite   the   bodies   of   the   first   and   second 
Fig.  XX.,  5.  11- 

lumbar    vertebrae,    and   between   the    thoracic 

aorta  on  the  left  and  the  vena  azygos  major  on  the  right. 
It  may  be  represented  on  the  surface  by  an  oval  enlarge- 
ment placed  just  to  the  right  of  the  middle  line,  occupying 
the  upper  two-thirds  of  the  space  between  the  transpyloric 
(first  lumbar)  and  subcostal  (third  lumbar)  planes. 

The  efferent  duct  pierces  the  diaphragm  through  the 

aortic  orifice  opposite  the  twelfth  dorsal  vertebra, 

Fig.  XX.,  6.  J        u  u 

and  passes  almost  vertically  upwards  through 

the  posterior  mediastinum,  just  to  the  right  of  the  middle 
line,  as  far  as  the  lower  part  of  the  fourth  dorsal  vertebra 
(Ludwig's  plane).  The  duct  now  crosses  behind  the 
oesophagus  to  the  left  of  the  middle  line,  and  then  again 
passes  vertically  upwards  through  the  superior  medias- 
tinum and  into  the  neck  as  far  as  the  level  of  the 
transverse     process    of    the    seventh    cervical    vertebra. 


48  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

Finally,  the  duct  curls  outwards  and  downwards  to  open 

into  the  angle  between  the  internal  jugular  and 
FifiT.  XX.,  7. 

subclavian  veins  of   the  left  side.      The  duct 

drains  the  whole  of  the  lymphatic  area  of  the  body,  except 

the  right  side  of  the  head  and  neck,  the  right  arm,  the 

right  side  of  the  thorax  and  the  convexity  of  the  liver,  the 

lymphatics  from  these  regions  draining  into  a  smaller  duct 

which  opens  into  the  angle  between  the  right   internal 

jugular  and  subclavian  veins. 


CHAPTER  IV 

THE  ABDOMEN 

The  anterior  aspect  of  the  trunk  (i.e.,  thorax  and  abdomen) 

Fig.  xviii.,    ^^  divisible  into  right  and  left  halves  by  a  median 

'  vertical   plane   from   the   middle   point   at   the 

suprasternal  notch  above  to  the  symphysis  pubis  below. 

Each  half  is  again  divided  by  a  lateral  vertical  plane  which 

Fig.  xviii.,     is  drawn  parallel  to  the  median  plane,  half-way 
4  4 
'    '  between  that  plane  and  the  anterior  superior 

iliac  spine.  Prolonged  downwards,  this  lateral  plane  crosses 
Poupart's  ligament  rather  nearer  to  the  inner  than  to  the 
outer  end.  Prolonged  upwards,  it  crosses  the  clavicle 
about  midway  between  the  median  point  at  the  supra- 
sternal notch  and  the  acromio-clavicular  joint. 

That  part  of  the  lateral  vertical  plane  which  traverses 
the  mammary  region  is  sometimes  called  the  "  mammary 
plane,"  that  part  which  crosses  the  clavicle  the  "  clavicular 
plane,"  and  the  downward  prolongation  which  cuts  across 
Poupart's  ligament  the  "  Poupart  plane." 

The  clavicular,  mammary,  and  Poupart  planes  are, 
however,  continuous,  and  they  together  form  the  lateral 
vertical  plane,  which  is  chosen  in  preference  to  the  mid- 
Poupart  plane  of  many  anatomists,  since  it  is  measured 
from  the  median  plane  to  a  fixed  bony  point.  Two  vertical 
planes  only  will  be  consequently  retained  in  the  subdivision 
of  the  anterior  aspect  of  the  trunk,  the  median  and  lateral 
vertical  planes. 

49 


50  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

The  median  plane  can  be  bisected  by  a  horizontal  plane 

which  is  on  the  same  level  as  the  body  of  the  first  lumbar 

vertebra.     This  plane  so  constantly  cuts  across  the  pyloric 

end  of  the  stomach  that  it  is  called  the  transpyloric  plane, 

and  it  w^ill  be  found  that  not  only  does  this 
Fig.  xviii. 

plane   lie   half-way   between   the    suprasternal 

notch   and   the   symphysis  pubis,    but    that    it  also   lies 

midway  between  the   umbilicus   and   the   sterno-xiphoid 

junction.     It   is,  therefore,   not   necessary  to  expose   the 

whole  of   the  anterior  aspect   of   the  trunk  in  order  to 

verify  the  position  of  the  transpyloric  plane,  a  plane  of  the 

greatest  value  in  defining  the  position  of  several  abdominal 

viscera.* 

The  point  at  which  the  median  vertical  and  transpyloric 

planes  intersect  has  been  suitably  called  the 
Fig.  xviii.,  1. 

"central  point,"  and  the  point  of  intersection 

of    the    lateral   vertical    and    transpyloric   planes    may   be 

tentatively  called  the  "  lateral  central "  or 
Fig.  xviii.,  2. 

"  paracentral  "  point.     This  latter  point  usually 

corresponds  to  the  anterior  extremity  of  the  ninth  costal 

cartilage. 

The  distance  between  the  "  central  point "  and  the  top 

of  the  symphysis  pubis  is  bisected  by  a  horizontal  plane 

which  passes  through  the  tubercles  of  the  iliac 
Fig.  xviii. 

crests,  the  intertuhercular  plane,  a  plane  corre- 
sponding to  the  level  of  the  body  of  the  fifth  lumbar 
vertebra.  It  has  also  been  suggested  that  the  distance 
between  the  "  central  point "  and  the  suprasternal  notch 
should  likewise  be  bisected  by  a  plane,  the  thoracic  plane, 
which  crosses  the  gladiolus  at  the  level  of  some  part  of 

*  N.B. — Most  of  the  "planes  "  mentioned  in  the  text  were  first  put 
forward  by  Dr.  C.  Addison,  Lecturer  and  Senior  Demonstrator  of 
Anatomy,  St.  Bartholomew's  Hospital,  to  whom  the  credit  is  due. 


THE  ABDOMINAL  AND  THORACIC  PLANES 


Level  of  hard  palate  =  first  cervical. 

Level  of  free  margin  of  upper  teeth  =  second  cervical. 

Level  of  hyoid  bone  =  second  to  third  cervical. 

Level  of  upper  part  of  thyroid  cartdage  =  fourth  cervical. 

Level  of  cricoid  caitilage  =  sixth  cervical. 


Supra- 
sternal 
plane 


Lud  wig's 

plane    "^ 


Thoracic 
plane 

Sterno- 

xiphoid 

plane 


Transpyloric 

plane  < 


Subcostal 
plane  ^ 

Umbilical  <- 
plane 

Intertuber- 
cular  plane  ** 

Spinous  _. 
plane 


Disc 
between 
2  and  3  D. 

Disc 
_^  Ijetwcen 
4  and  5  D. 


Disc 
between 
9  and  10  D. 


Below  sacral 
promontory 


FIG.  XVII r. 

1,  The  central  point. 

2,  2.  The  latc-rril  central  or  paracentral  point. 

3,  3.  The  median  vertical  plane. 

4,  4.  The  lateral  vertical  plane. 

5,  5.  The  niid-I'ou])art  point. 

6,  6.  The  pubic  spines. 


To  /ace  />•  50- 


THE    ABDOMEN  5I 

the  anterior  extremities  of   the  fourth  costal  cartilages. 

This  plane  is,  however,  of  little  value,  and  is 
Fig.  xviii. 

merely  mentioned  as  completing  the  sym- 
metrical subdivision  of  the  median  vertical  plane  into 
four  equal  parts. 

The  following  planes  are,  therefore,  chosen  as  the  most 
scientific  in  the  subdivision  of  the  anterior  aspect  of  the 
trunk : 

Two  vertical  planes — (i)  The  median ;  (2)  the  lateral. 

Three  transverse  planes — (i)  The  intertubercular;  (2)  the 
transpyloric ;  (3)  the  thoracic. 

Two  important  points  are  also  named — (i)  The  central 
point ;  (2)  the  lateral  central  point. 

The  abdominal  regions  mapped  out  by  the  intersection 
of  the  transpyloric  and  intertubercular  planes  with  the 
lateral  vertical  planes  receive  the  same  nomenclature  as  in 
the  older  methods  of  regional  subdivision  of  the  abdomen. 
These  regions  are  nine  in  number : 

I.  Right  hypochondriac.     2.  Epigastric.     3.  Left  hypo- 
chondriac.     4.    Right    lumbar.      5     Umbilical. 
Fig.  xviii.  •,*<-.      tt 

6.  Left  lumbar.  7.  Right  iliac.  8.  Hypo- 
gastric.    9.  Left  iliac. 

Other  Transverse  Planes,  with  their  Correspond- 
ing Vertebral  Levels. 
(a)  The   suprasternal  plane,    on    a   level   with   the  disc 

between  the  second  and  third  dorsal  vertebrae. 
RicT.  xviii. 

(b)  Ludwif!;'s  plane   (junction  of   manubrium 

and  gladiolus),  on  a  level  with  the  disc  between  the  fourth 

and  fifth  dorsal  vertebrae. 

(c)  The  sterno-xiphoid  plane   (junction  of   sternum  and 

xiphoid  cartilage),  on  a  level  with  the  disc  between  the 

ninth  and  tenth  dorsal  vertebra;. 


52  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

(d)  The  subcostal  plane,  on  a  level  with  the  lower  part  of 
the  third  lumbar  vertebra. 

(e)  The  umbilical  plane,  on  a  level  with  the  disc  between 
the  third  and  fourth  lumbar  vertebrae. 

(/)  The  spinous  plane,  drawn  between  the  two  anterior 
superior  iliac  spines,  and  usually  falling  below  the  level  of 
the  sacral  promontory. 

The  linec^  semilunares  correspond  to  the  outer  border 

Fiff.  XX.        o^   the   rectus  abdominis    muscle,   and  extend, 

'^'  with  a  slight  outward  convexity,  from  the  pubic 

spine  below  to  the  tip  of  the  ninth  costal  cartilage  above 

(the  lateral  central  point). 

The  linec^  transverse^  result  from  the  tendinous  inter- 
Fie.  XX.  13  sections  in  the  rectus  abdominis  muscle.  They 
13, 13.  g^j-g  three  in  number,  and  are  situated — (i)  at 
the  level  of  the  umbilicus;  (2)  midway  between  the 
umbilicus  and  the  xiphoid  cartilage ;  (3)  immediately 
below  the  xiphoid  cartilage. 

The  semilunar  fold  of  Douglas,  representing  the  lower 

limit  of   the   posterior   lamella   of    the   rectus 
Fig.  XX.,  14.  ^ 

sheath,  lies  about  half-way  between  the   um- 
bilicus and  the  upper  border  of  the  pubic  symphysis. 
The  umbilicus   usually  lies    i   to   i^-  inches   above  the 

intertubercular  plane,  and  corresponds  to  the 
Fig.  xviii. 

level  of  the  disc  between  the  third  and  fourth 

lumbar  vertebrae.  The  umbilicus  is,  however,  so  incon- 
stant in  position  that  the  umbilical  plane  is  rejected  as 
often  as  possible  in  favour  of  a  more  definite  and  scientific 
plane. 

The  iliac  spines  and  crest. — When  the  body  is  in  the 
Figs  xxii     dorsal  recumbent  position,  the  anterior  superior 

^'^"'-  iliac  spine  is  usually  visible  to  the  eye,  and  no 
palpation  is  needful  in  order  to  fix  its  position.     In  the 


THE    ABDOMEN  53 

obese,  however,  it  is  generally  necessary  to  trace  forward 
the  iliac  crest  to  its  anterior  termination.  By  tracing  the 
iliac  crests  in  a  backward  direction  the  "  iliac  tubercles  " 
will  be  found,  lying  about  2  to  2^  inches  behind  the 
anterior  superior  spines,  and  a  line  uniting  these  two 
tubercles  (the  intertubercular  plane)  corresponds  to  the 
level  of  the  fifth  lumbar  vertebra.  Still  further  backward, 
the  posterior  superior  iliac  spines  will  be  found  at  the 
Fig.  xvii  posterior  termination  of  the  iliac  crest.  A  line 
'  which  joins  the  posterior  superior  iliac  spines 

cuts  across  the  spine  of  the  second  sacral  vertebra. 

The  pubic  spine  lies  at  the  outer  limit  of  the  pubic  crest. 
Fig.  xviii.,  Iri  the  male,  it  is  advisable  to  invaginate  the 
Fie  xxii       scrotum  in  order  to  locate  the  position  of  this 

2i  2.  spine ;    whilst    in    the    female,   owing    to    the 

prominence  of  the  mons  veneris,  it  is  usually  necessary 
to  abduct  the  thigh,  to  feel  for  the  rounded  tendon  of  the 
adductor  longus  muscle,  and  to  trace  this  tendon  up  to 
its  origin  from  a  depression  on  the  pubic  bone,  which  is 
situated  immediately  below  and  internal  to  the  pubic 
spine. 

In  the  erect  position  of  the  body  the  symphysis  pubis 
is  nearly  horizontal,  the  inner  or  pelvic  surface  looking 
upwards  and  only  slightly  backwards,  whilst  the  external 
surface  faces  downwards  and  a  little  forwards.  The  pubic 
crest  is  therefore  practically  directed  forwards  and  the 
pubic  arch  backwards.  A  knife  inserted  horizontally 
backwards  immediately  above  the  pubic  symphysis  would 
pass  above  the  upper  limit  of  the  prostate  gland  and  below 
the  promontory  of  the  sacrum  ;  whilst  if  directed  hori- 
zontally backwards  below  the  symphysis  pubis,  it  would 
pierce  the  prostate  near  its  centre  and  pass  below  the  level 
of  the  tip  of  the  coccyx. 


54  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

The  inguinal  canal. — In  the  adult  this  canal  is  about 
Fig.  XX.,  19,  ij  inches  long,  and  extends  from  the  internal 
Fig  XX.  17  to  t^^  external  abdominal  rings.  The  internal 
^^-  abdominal  ring,  a  funnel-shaped  prolongation  of 

the  transversalis  fascia,  is  situated  f  inch  above  the  mid- 
point of  Poupart's  ligament.  The  external  abdominal  ring, 
Fig.  XX.,  18,  formed  by  the  splitting  of  the  aponeurosis  of 
the  external  oblique  muscle,  is  triangular  in 
shape,  the  base  directed  downwards  and  inwards  and 
opening  up  immediately  above  the  pubic  spine,  whilst  the 
apex  is  directed  upwards  and  outwards. 

Petifs  triangle. — This  triangle  is  bounded  in  front  by 
the  posterior  border  of  the  external  oblique,  and  behind 
by  the  anterior  border  of  the  latissimus  dorsi  muscle, 
whilst  the  base  is  formed  by  part  of  the  iliac  crest.  The 
external  oblique  is  inserted  into  the  anterior  half  of  the 
iliac  crest,  and  the  base  of  the  triangle  corresponds  to 
I  to  2  inches  of  the  bone  behind  the  mid-point  of  the 
crest.  The  triangle  is  subject  to  great  variation  in  size, 
the  two  bounding  muscles  converging  rapidly  above  to 
form  the  apex  of  the  triangle.  The  floor  is  formed  by  the 
internal  oblique  muscle. 

The  Alimentary  Canal. 

The  stomach. — Capacity  about  2  pints.  The  cardiac 
orifice  lies  opposite  the  eleventh  dorsal  vertebra, 
■'  '  and  is  situated  about  4  inches  away  from  the 
surface.  It  corresponds  in  position  to  a  point  on  the 
seventh  costal  cartilage  |  inch  away  from  the  outer 
border  of  the  sterno -xiphoid  junction.  The  seventh 
costal  cartilage  is  the  lowest  of  the  series  of  cartilages 
which  articulate  in  front  with  the  mesial  sterno-xiphoid 
bar,  and  forms,  therefore,  the  upper  lateral  boundary  of 


THE    ABDOMEN  55 

the  epigastric  triangle.     The  pyloric  orifice  hes  opposite 

the  first  lumbar  vertebra,  and  corresponds  in 
Fip-    xix    3  •   • 

■'    ■   position  to  a  point  in  the  transpyloric  plane 

just  to  the  right  of  the  middle  line. 

The  lesser  curvature  is  represented  by  a  curved  line,  con- 
vexity to  the  left,  uniting  the  above  two  points.  The 
greater  curvature,  in  the  moderately  distended  condition  of 
the  stomach,  ascends  to  the  lower  border  of  the  left  fifth 
costal  cartilage  and  rib,  lying  immediately  above  and 
behind  the  apex  of  the  heart.  Sweeping  then  downwards, 
the  greater  curvature  usually  cuts  the  left  costal  margin  at 
some  part  of  the  ninth  costal  cartilage,  and  finally  curves 

upwards   and   inwards   to   the    pylorus.      The 
Fig.  XX.,  1.  .      .        .  . 

upper  limit  of  the  fundus  of  the  stomach  corre- 
sponds to  the  level  of  the  left  dome  of  the  diaphragm. 

The  duodenum. — Total  length,  about  lo  inches.     Part  i 
Fig.  xix.,  4,   ^2  inches;  part  2  =  3  to  4  inches;  part  3  =  4  to 
'  ^'        5  inches. 

The  pyloric  orifice  of  the  stomach  lies  opposite  the  first 
lumbar  vertebra,  and  the  first  part  of  the  duodenum  is 
directed  backwards,  with  a  slight  inclination  upwards,  to 
the  right  side  of  the  body  of  the  first  lumbar  vertebra. 

Part  2  descends,  on  the  right  side  of  the  median  vertical 
plane,  from  the  level  of  the  first  lumbar  vertebra  (trans- 
pyloric plane)  to  the  level  of  the  third  lumbar  vertebra 
(subcostal  plane).  The  third  part  of  the  duodenum  passes 
almost  transversely  across  the  middle  line  at  the  level 
of  the  subcostal  plane,  and  having  reached  the  left 
Fig  xix.,      side   of    the   middle   line,   ascends   sharply   to 

^'  the  duodeno-jejunal  flexure,  which  is  placed  on 

a  level  with  the  second  lumbar  vertebra,  just  below  the 
transpyloric  plane,  and  i  to  i^  inches  to  the  left  of  the 
middle  line.     The  duodenum  is  subject  to  great  variation 


FIG.  XIX. 

1,  I.  The  oesophagus. 

2.  The  stomach. 
1..  The  pylorus. 

4,  4,  4.  The  three  parts  of  the  duodenum.     4'-  The  pancreas. 
:;'.  The  duodeno-jejunal  flexure. 

6.  The  attachment  of  the  mesentery  of  the  small  intestine. 

7.  The  ileo-csecal  valve. 

8.  The  caecum. 

9.  The  vermiform  appendix. 

10.  The  ascending  colon. 

11.  The  hepatic  flexure. 

12.  The  splenic  flexure. 

13.  The  descending  colon. 

14.  The  iliac  colon. 

15.  The  ilio-pelvic  colon. 

16.  The  gas tro -hepatic  omentum. 
17    The  foramen  of  Winslow. 

18.  The  common  bile-duct. 
N.B.— The  transverse  colon  has  been  intentionally  omitted. 


THE  ALIMENTARY  CANAL 


FIG.  XIX. 

a,  a,  and  a',  a'  =  \.\\q  lateral  vertical  planes. 

b,  h.  The  transpyloric  plane. 

c,  c.  The  subcostal  ]>lane. 

d,  d.  The  intertubercular  plane. 


To /ace  p.  56. 


THE    ABDOMEN  57 

The  vermiform  appendix. — The  opening  of  the  appendix 
Fig.  xix.,      ^"t°    the   caecum    is   situated  just    below   and 

®-  internal    to    the  junction    of   the    right    lateral 

vertical  and  intertubercular  planes,  at  the  top  right-hand 
corner  of  the  hypogastric  region.  The  surface  marking  of 
the  csecal  orifice  of  the  appendix  does  not  coincide  with 
McBurney's  point,  which  is  situated  at  the  junction  of 
the  outer  and  middle  thirds  of  a  line  drawn  from  the 
right  anterior  superior  iliac  spine  to  the  umbilicus.  This 
point  represents  the  usual  seat  of  maximum  pain  on 
palpation  in  an  attack  of  appendicitis.  The  appendix 
is  usually  3  to  4  inches  long,  and,  according  to  Testut, 
is  in  40  per  cent,  of  cases  directed  downwards  and 
inwards,  overhanging  the  pelvic  brim,  whilst  in  26  per 
cent,  of  cases  only  is  it  directed  upwards  and  inwards 
(towards  the  spleen).  Stress  should  be  laid  on  the  fact 
that  the  ileo-caecal  valve  and  the  caecal  orifice  of  the 
appendix  are  both  situated  on  the  postero-internal  aspect 
of  the  caecum. 

The  ascending  colon  passes  upwards  from  the  level  of 
Fig.  xix.,  the  intertubercular  plane  to  the  upper  part  of 
the  ninth  right  costal  cartilage,  the  gut  there 
turning  on  itself  to  form  the  hepatic  flexure.  In  its 
upward  course  the  ascending  colon  lies  almost  entirely 
to  the  right  of  the  right  lateral  vertical  plane. 

The  transverse  colon  extends  from  the  hepatic  flexure  on 
Fie  xix        ^he  right  to  the  splenic  flexure  on  the  left.     The 

"•  former  flexure  corresponds  to  the  ninth  costal 

cartilage,  whilst  the  latter  reaches  upwards  as  high  as  the 
eighth.  In  between  these  two  points  the  gut  varies  greatly 
in  direction  in  different  subjects.  Most  commonly  the 
gut  passes  almost  transversely  from  one  side  to  the  other, 
crossing  the  middle  line  at  about  the  level  of  the  second 

5-2 


58  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

lumbar  vertebra.  It  also  crosses  the  second  part  of  the 
Fiff.  xix.,  duodenum,  and  lies,  therefore,  usually  above 
the  umbilical  plane.  In  the  diagram  the  two 
flexures  are  dep  cted,  but  the  intervening  portion  of  the 
gut  has  been  intentionally  omitted. 

The  descending  colon  passes  almost  vertically  downwards 
Fig.  xix.,  from  the  region  of  the  splenic  flexure  to  the 
level  of  the  posterior  part  of  the  iliac  crest,  below 
which  level  it  becomes  known  as  the  iliac  colon.  The 
descending  colon  lies  wholly  to  the  left  of  the  left  lateral 
vertical  plane. 

The  operation  of  lumbar  colotomy  is  now  seldom 
Fig.  xvii.,  performed,  but  it  is  nevertheless  necessary  to 
indicate  the  position  of  the  descending  colon 
on  the  posterior  aspect  of  the  trunk.  It  corresponds  in 
direction  to  a  line  drawn  vertically  upwards  to  the  tip  of 
the  last  rib,  from  a  point  situated  J  inch  behind  the  mid- 
point along  the  iliac  crest  between  the  anterior  and 
posterior  superior  iliac  spines. 

The  iliac  and  pelvic  colon. — Between  the  termination 
of  the  descending  colon  at  the  level  of  the  iliac  crest,  and 
the  beginning  of  the  rectum  proper  at  the  level  of  the 
third  piece  of  the  sacrum,  the  large  gut  describes  so  varied 
a  course  that  no  definite  detailed  account  can  be  given  of 
its  surface  marking.  It  may,  however,  be  briefly  described 
Fig.  xix.,      3-S  passing  downwards  and  inwards  from  the 

^'*'  level  of   the  iliac  crest,   parallel  to   Poupart's 

ligament,  as  far  as  the  left  side  of  the  pelvic  brim  (the 
iliac  colon).  The  gut  then  forms  a  great  loop  (the  pelvic 
Fig.  xix.,  colon),  which  sweeps  over  to  the  right  side  of 
the  pelvic  brim,  turning  on  itself  to  become  the 
rectum  at  the  level  of  the  third  sacral  vertebra. 

The  rectum. — A   line  which  unites   the   two   posterior 


THE    ABDOMEN 


59 


superior  iliac  spines  crosses  the  spinous  process  of   the 
Fig.  xvii.,     second  sacral  vertebra.     The  rectum  begins  at 
the  level  of  the  third  sacral  vertebra,  and  may 
be  indicated  on   the  surface   by  drawing  in   the   gut   as 
starting  about  ^  to  f  inch  below  the  above-mentioned  line, 
and   extending  downwards,  following  the  curves  of   the 
sacrum  and  coccyx,  to  the  anal  orifice,  which  is  placed 
about  2  inches  below  the  level  of  the  tip  of  the  coccyx. 
The  dura  mater  enclosing  the  spinal  cord  (see  ^^  spinal 
cord'')  reaches  downwards  to  the  level  of  the 
third  sacral  vertebra.     The  spinal  dura,  there- 
fore, terminates  at  the  same  level  as  the  rectum  begins,  a 
point  to  be  borne  in  mind  in  those  operations  carried  out 
in  the  sacral  region  for  the  exposure  of  a  growth  involving 
the  gut  in  the  neighbourhood  of  the  ilio-pelvic  and  rectal 
junction. 

The  Kidney 

{Length,  4^  inches;  breadth,  2 J  inches;   thickness, 

1 1  inches;  weight,  4I  ounces). 

{a)  Anterior  surjace  marking. — The  two  kidneys  are 
Fig.  XV.        obliquely  placed    in    such    a   manner   that  the 

^^-  superior  poles  lie  i|  to  2  inches,  and  the  inferior 

poles  2h  to  3  inches,  distant  from  the  middle  line.  The 
left  kidney  lies  at  a  slightly  higher  level  than  its  fellow, 
and  the  hilum  is  placed  just  below  and  in-ternal  to  the 
junction  of  the  transpyloric  and  left  lateral  vertical 
planes ;  or,  in  other  words,  the  hilum  of  the  left  kidney  lies 
just  internal  to  the  anterior  extremity  of  the  ninth  costal 
cartilage.  The  upper  pole  lies  half-way  between  the  sterno- 
xiphoid  and  transpyloric  planes,  whilst  the  lower  pole 
corresponds  to  the  subcostal  plane.  The  right  kidney  does 
not  ascend  to  quite  such  a  high  level,  and  the  inferior  pole 


60  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

lies  opposite  the  umbilical  plane.  The  hilum  of  this  kidney 
also  lies  just  below  the  level  of  the  hilum  of  the  opposite 
kidney. 

(b)  Posterior  surface  marking — Morris's  quadrilateral. — 
Fig.  xvii.       Two  vertical  lines  are  drawn  at  a  distance  of 

'^-  I    inch   and   3^   inches   respectively  from   the 

median  posterior  line,  and  two  horizontal  lines  are  drawn 
outwards  at  the  level  of  the  spinous  processes  of  the 
eleventh  dorsal  and  third  lumbar  vertebrae.  In  the  quadri- 
lateral so  marked  out,  the  kidneys  are  drawn,  care  being 
taken  to  place  the  long  axis  of  each  kidney  in  the  required 
oblique  direction. 

The  Ureters 

{Length,  10  inches'). 

(a)  Anterior  surface  marking. — The  ureter  passes  nearly 
Fig.  XV.  vertically  downwards  from  the  hilum  of  the 
kidney  (just  below  and  internal  to  the  junction 
of  the  transpyloric  and  lateral  vertical  planes),  and  dips 
into  the  true  pelvis  in  close  relation  to  the  bifurcation 
of  the  common  iliac  artery.  This  vessel  bifurcates  into 
internal  and  external  iliacs  at  the  junction  of  the  upper 
and  middle  thirds  of  a  line  drawn  from  a  point  ^  inch 
below  and  to  the  left  of  the  umbilicus  (the  aortic  bifurca- 
tion) to  a  second  point  situated  half-way  between  the 
anterior  superior  iliac  spine  and  the  symphysis  pubis. 
This  apparently  complicated  surface  marking  for  the  ureter 
will  be  rendered  more  easy  by  a  reference  to  the  diagram. 
The  right  ureter  generally  dips  into  the  pelvis  just  below 
the  bifurcation  of  the  common  iliac  artery. 

(&)  Posterior  surface  marking. — The  course  of  the  ureter 
Fig.  xvii.       on  the  posterior  aspect  of   the  trunk  can  be 

^^'  represented  by  a  line  drawn  vertically  upwards 


THE    ABDOMEN  6l 

from  the  posterior  superior  iliac  spine  to  the  level  of  the 
spinous  process  of  the  second  lumbar  vertebra. 

The  ovary  lies  in  the  angle  between  the  internal  and 
Fig  XV  external  iliac  arteries,  immediately  below  the 
pelvic  brim  and  anterior  to  the  ureter. 

The  urachus  is  directed  upwards  from  the  apex  of  the 
Fig.  XX.        bladder,   at    the    upper    border    of    the    pubic 

'^"  symphysis,  to  the  umbihcus. 

Abdominal  Vessels. 

The  abdominal  aorta. — The  thoracic  aorta  enters  the 
Fig.  XV.,       abdominal  cavity  by  passing  beneath  the  middle 

^^"  arcuate  ligament  of  the  diaphragm  at  the  level 

of  the  twelfth  dorsal  vertebra.  The  vessel  then  changes 
its  name,  and  the  abdominal  aorta  passes  vertically 
downwards  as  far  as  the  left  side  of  the  body  of  the  fourth 
lumbar  vertebra,  at  which  level  it  bifurcates  into  the  two 
common  iliac  arteries.  The  course  of  the  vessel  may  be 
mapped  out  on  the  surface  by  taking  a  point  about  two 
fingers'  breadth  above  the  transpyloric  plane  and  slightly 
to  the  left  of  the  middle  line,  and  by  drawing  a  line  verti- 
cally downwards  to  a  second  point  situated  ^  inch  below 
and  to  the  left  of  the  umbilicus. 

The  first  large  vessel  which  arises  from  the  abdominal 
p;o-  vw         aorta  is  the  cceliac  axis.     This  trunk  is  given  off 

^^-  at  the  level  of  the  twelfth  dorsal  vertebra,  and 

divides,  after  a  course  of  about  ^  inch,  into  three  main 
trunks— the  hepatic,  splenic,  and  coronary  or  gastric 
arteries. 

The  superior  mesenteric  (level  of  disc  between  the  twelfth 
Fig.  XV.,       dorsal  and  the   first  lumbar  vertebrae)  follows 

^^-  next,  springing  from  the  anterior  aspect  of  the 

aorta  immediately  above  the  transpyloric  plane. 


62  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

The  renals  (level  of  the  first  lumbar  vertebra)  pass  out- 
Fig.  XV.,       wards   from    the    lateral    aspect    of    the    aorta 

immediately  below  the  level  of  the  trans- 
pyloric  plane. 

The    inferior    mesenteric     (level    of    the    third    lumbar 
Fig.  XV.,       vertebra)  arises  from  the  left  side  of  the  main 

trunk  at  about  the  level  of  the  subcostal  plane. 
The  common  iliac  artery  corresponds  to  the  upper  third 
Fig.  XV.        of  a  line  drawn  from  a  point  |  inch  below  and 

to  the  left  of  the  umbilicus  to  a  second  point 
situated  half-way  between  the  anterior  superior  iliac  spine 
Fig.  XV.         3-^d  the   symphysis    pubis.     The    external  iliac 

artery  corresponds  in  direction  to  the  lower 
two-thirds  of  this  line. 

The  deep  epigastric  artery  is  given  off  from  the  external 
Fig.  XX.,       ili^-c  just  as  that  vessel  passes  under  Poupart's 

ligament  half-way  between  the  anterior  superior 
iliac  spine  and  the  symphysis  pubis.  The  epigastric  artery 
then  passes  upwards  and  inwards  along  the  inner  side 
of  the  internal  abdominal  ring  towards  a  point  situated 
^  inch  to  I  inch  outside  the  umbilicus,  entering  the 
rectus  sheath  at  the  level  of  the  semilunar  fold  of 
Douglas. 

This  vessel  forms  the  outer  boundary  of  Hesselbach's 
Fig.  XX.,       triangle,  the  inner  boundary  of  this  space  being 

formed  by  the  linea  semilunaris  of  the  same 
side,  and  the  base  by  Poupart's  ligament.  Each  triangle 
is  vertically  subdivided  into  two  parts  by  the  obliterated 
hypogastric  artery,  on  either  side  of  which  herniae  may 
protrude. 

The  inferior  vena  cava  is  formed  by  the  junction  of  the 
two  common  iliac  veins  on  the  right  side  of  the  body  of 
the  fifth  lumbar  vertebra,  about  i  inch  below  and  |  inch 


FIG.  XX. 

1.  I.  The  diaphragm. 

2.  The  liver. 

3.  The  gall-bladder. 

4.  The  ligamentum  teres. 

5.  The  receptaculum  chyli. 

6.  The  thoracic  duct. 

7.  The  venous  termination  of  the  duct. 

8.  The  internal  mammary  artery. 

9.  The  superior  epigastric  artery. 
ID.  The  musculo-phrenic  artery. 

11.  The  rectus  abdominis  muscle. 

12,  12.  The  linse  semilunares. 
I3>  I3»  13-  The  linse  transversae. 

14.  The  semilunar  fold  of  Douglas. 

15.  The  nrachus. 

16.  Hesselbach's  triangle. 

17.  17.  The  internal  abdominal  ring. 

18.  18.  The  external  abdominal  ring. 

19.  19.  The  inguinal  canal. 

20.  The  deep  epigastric  artery. 


THE   LIVER,  ANTERIOR  ABDOMINAL  WALL,   ETC. 


riG.  XX, 


'I'o/ncc  />.  62. 


THE   ABDOMEN  63 

to  the  right  of  the  umbilicus.  The  vein  passes  upwards 
Fig.  XV.,  ^^  pierce  the  quadrate  opening  of  the  diaphragm 
at  the  level  of  the  eighth  dorsal  vertebra, 
entering  the  right  auricle  of  the  heart  opposite  the  fifth 
right  interspace  and  the  adjoining  part  of  the  sternum. 

The  Liver. 

The  anterior  border  can  be  mapped  out  by  drawing  a 

curved    line    from    a    point    in    the    fifth    left 
F iff   XX     2 

interspace  3^^  inches  from  the  middle  line  (the 
position  of  the  apex  of  the  heart),  the  line  cutting  the 
left  costal  margin  at  the  tip  of  the  eighth  costal  cartilage 
and  the  right  costal  margin  at  the  tip  of  the  ninth  costal 
cartilage.  Between  these  two  latter  points,  the  anterior 
border  of  the  liver  crosses  the  middle  line  half-way  between 
the  umbilicus  and  the  sterno-xiphoid  junction  (  =  trans- 
pyloric  plane),  whilst  a  notch  to  the  right  of  the  middle 
line  indicates  the  hepatic  attachment  of  the 
ig.  XX.,  .  ^j-^^jjjgjjf^^jj^  teres,  which  passes  from  that  notct 
downwards  and  inwards  to  the  umbilicus. 

Beyond  the  tip  of  the  ninth  right  costal  cartilage  the 

anterior  border  of  the  liver  follows  the  lower  limit  of  the 

costal  arch,  descending  sometimes  even  below  that  level, 

Fig.  xvii.,     and  after  cutting  across  the  twelfth  rib,  ascends 

'^-  towards  the  level  of  the  eleventh  dorsal  spine. 

The  iippcr  limit  of  the  liver  is  indicated  by  a  line  starting 

as  before  in  the  fifth  left  interspace  3J  inches 

'^'  '''^'        from  the  middle  line,  and  ascending  slightly  as 

it  passes  to  the  right.     This  line   cuts  across  the  sixtii 

Fig.  xvii,      t"'??^*    chondro-sternal    articulation,    the    upper 

^2-      '     border  of  the  right  fifth  costal  cartilage  in  the 

right  lateral  vertical  plane,  the  sixth  rib  in  the  mid-axillary 


64  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

line,  sweeping  thence  just  below  the  angle  of  the  scapula 
towards  the  eighth  dorsal  spine. 

The  gall-bladder. — The  fundus  projects  from  under  the 

anterior  border  of  the  liver  in  the  angle  between 

*'    '  the  tips  of  the  ninth  and  tenth  costal  cartilages 

and  the  outer  border  of  the  rectus  abdominis  muscle. 

The  diaphragm. — On  ordinary  inspiration  the  right  dome 

of  the  diaphragm  corresponds  in  level  to  the 

*'  '    lower  part  of  the  fourth  right  interspace,  whilst 

the  left  dome  ascends  to  the  lower  part  of  the  fifth  left  rib 

and  costal  cartilage. 

The  Common  Bile-du-ct,  etc. 

The  gastro-hepatic  omentum,  passing  upwards  from  the 
Fig.  xix.  lesser  curvature  of  the  stomach  to  the  trans- 
verse fissure  of  the  liver,  presents  a  free  edge, 
which  looks  downwards  and  to  the  right,  and  which  forms 
the  anterior  boundary  of  the  foramen  of  Winslow,  the 
pj     ^^^^        channel  of  communication  between  the  greater 

'^*  and  the  lesser  peritoneal  sacs.     The  free  edge 

of  this  omentum  further  contains  (between  its  two  layers 
of  peritoneum)  three  important  structures  : 

1.  The  common  bile-duct  to  the  right. 

2.  The  hepatic  artery  to  the  left. 

3.  The  portal  vein  behind  and  between  the  two  former 
structures. 

In  mapping  out  any  of  these  structures,  it  is,  therefore, 
advisable  to  first  draw  in  the  lesser  curvature  of  the 
stomach,  the  pylorus,  the  three  parts  of  the  duodenum, 
and  the  pancreas.  The  pylorus  occupies  such  a  definite 
position  in  the  transpyloric  plane  that  all  these  structures 
are  easily  and  quickly  drawn  in.  The  free  margin  of  the 
lesser  omentum  should  be  represented  as  a  curved  line 


THE    ABDOMEN  65 

passing  upwards  and  to  the  right  for  i^  to  2  inches  from 
the  duodeno-pyloric  junction.  The  portal  vein  is  formed 
behind  the  head  of  the  pancreas  by  the  union  of  the 
superior  mesenteric  and  splenic  veins,  and  passes  up- 
wards to  the  transverse  fissure  of  the  Hver  behind  the 
first  part  of  the  duodenum,  and  in  the  free  edge  of  the 
lesser  omentum. 

The  hepatic  artery,  a  branch  of  the  coeliac  axis,  passes 
upwards  from  the  upper  border  of  the  first  part  of  the 
duodenum,  in  the  free  edge  of  the  lesser  omentum,  to  the 
transverse  fissure  of  the  liver. 

The  common  bile-duct  is  3  inches  long,  and  is  formed 
Fie  xix        ^y  ^^^  union  of  the  hepatic  and  cystic  ducts. 

'^'  It  passes  downwards  in  the  free  edge  of  the 

gastro-hepatic  omentum,  behind  the  first  part  of  the 
duodenum,  behind  the  head  of  the  pancreas,  and  opens 
on  the  inner  and  posterior  aspect  of  the  second  or 
descending  part  of  the  duodenum. 

The  Spleen, 

The  long  axis  of  the  spleen  corresponds  to  the  tenth 
Fig.  xvii.,     "b,   and   the   viscus   extends    upwards   to   the 

^-  upper  border  of  the  ninth  rib,  and  downwards 

to  the  lower  border  of  the  eleventh  rib.  The  upper  and 
inner  pole  lies  i^  to  2  inches  away  from  the  tenth  dorsal 
spine,  whilst  the  lower  or  anterior  pole  reaches  as  far 
forwards  as  the  mid-axillary  line. 

The  Spinal  Cokd. 

The  spinal  cord  extends  from  the  foramen  magnum  to 

the  lower  border  of  the  first  lumbar  vertebra 

Fi|'  xvii ,       (transpyloric    plane).      The   cord   follows   the 

curves  of  the  vertebral  column,  and  presents 


66  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

also  two  enlargements,  the  intumescentia  cervicalis  and 

lumbalis.     The   former   swelling   lies   between  the  third 

cervical  and  second  dorsal  vertebrae,  the  latter  between  the 

ninth  and  twelfth  dorsal  vertebrae.     Near  its  termination 

the  cord  tapers  away  as  the  conus  medullaris. 

The  filum  terminale,   the  prolongation  of  the  cord,  is 

continued  onwards  from  the  lower  part  of  the 
Fig.  vii.,  7. 
Fig.  xvii.,       body  of  the  first  lumbar  vertebra  to  near  the 

tip  of  the  coccyx,  at  which  level  it  blends  with 

the  periosteum  lining  that  bone. 

The  theca  vertebralis,  or  dural  sheath,   extends  as  low 

Fig.  vii.,  6.     as  the  third  sacral  vertebra,  at  which  level  it  is 
Fid  xvii. 

1, 1,    '       pierced  by  the  filum  terminale. 

A  line  uniting  the  two  posterior  superior  iliac  spines 

..    ,_     cuts  across  the  second  sacral  spine,   and  the 
Fig.  vii.,  10.  .  . 

Fig.  xvii.,      dural  sac,  therefore,  terminates  about  |  inch 

below  the  level  of  this  interspinous  line.    At  the 

third  month  of  intra-uterine   life  the   cord  extends  the 

whole   length  of  the  vertebral  canal,  whilst  at  birth  it 

reaches  as  low  down  as  the  third  lumbar  vertebra. 

A  reference  to  Fig  y  will  show  that  cerebro-spinal  fluid 

might    be   withdrawn    from    the   thecal   canal   anywhere 

between  the  termination  of  the  cord  at  the  level  of  the 

transpyloric  plane  and  the  base  of  the  sacrum.     A  line 

drawn  across  the  back,  at  right  angles  to  the  long  axis  of 

the  body,  at  the  level  of  the  highest  part  of  the  iliac  crests, 

cuts  across  the  median  posterior  line  at  the  level  of  the 

interspace  between  the  laminae  of  the  second  and  third  or 

third  and  fourth  vertebrae.     It  is  at  this  point,  or  rather  to 

one  side  of  this  point,  that  lumbar  puncture  is  carried  out. 


THE   ABDOMEN  67 

THE  PERINEUM. 

A  brief  account  only  will  be  given,  as,  though  the 
landmarks  are  most  important,  the  tendency  is  great  to 
drift  into  the  question  of  surgical  applied  anatomy,  a  pitfall 
which  the  writer  is  most  anxious  to  avoid. 

The  perineum  is,  in  shape,  roughly  quadrilateral,  the 
lateral  boundaries  being  formed  in  front  by  the  diverging 
rami  of  the  pubis  and  ischium,  and  behind  by  the  ischial 
tuberosity  and  the  gluteus  maximus  muscle.  The  anterior 
and  posterior  angles  of  the  space  are  formed  respectively 
by  the  symphysis  pubis  and  the  tip  of  the  coccyx.  The 
subpubic  angle  is  obtuse  in  the  female  and  acute  in  the 
male.  In  the  female,  also,  the  ischial  tuberosities  are 
further  apart  and  slightly  everted.  The  perineum  is 
divided  into  two  areas  by  a  line  drawn  between  the 
anterior  part  of  the  ischial  tuberosities,  thus  forming — 

{a)  The  genital  area. 
(6)  The  rectal  area. 

This  transverse  line  passes  about  i  inch  in  front  of  the 
anus,  and  represents  the  level  of  the  two  transverse  perinei 
muscles,  the  posterior  border  of  the  triangular  ligament, 
and  the  line  along  which  Colles's  fascia  is  reflected  round 
the  posterior  border  of  the  two  transverse  perinei  muscles 
to  become  continuous  with  the  posterior  border  of  the 
triangular  ligament.  The  "  central  tendinous  point  of  the 
perineum "  corresponds  to  the  middle  of  this  line,  and 
forms  the  point  of  attachment  of  several  muscles. 

{a)  The  genital  area.~ln  the  male,  this  area  is  divided 
into  two  lateral  triangles  by  the  median  antero-posterior 
prominence  of  the  bulb  of  the  penis  (corpus  spongiosum). 
The  two  crura  of  the  penis  (corpora  cavernosa)  diverge  as 


68  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

they  pass  backwards  towards  the  tuberosity  of  the  ischium, 
and  the  main  pudic  vessels  He  under  cover  of  these 
erectile  organs.  The  triangle  is  completed  behind  by 
the  transversus  perinei  muscle.  All  the  above-mentioned 
erectile  structures  and  muscles  lie  superficial  to  the 
triangular  ligament. 

In  the  female,  this  area  is  practically  cut  into  two  lateral 
triangles  by  the  orifice  of  the  vagina,  each  side  of  which 
lies  the  bulb  of  the  vestibule,  an  organ  of  erectile  tissue, 
corresponding  developmentally  to  the  male  corpus  spon- 
giosum. More  superficially,  the  two  labia  majora  converge 
towards  the  mons  veneris  in  front,  whilst,  on  the  mesial 
aspect  of  the  labia  majora,  the  labia  minora  converge 
towards  the  clitoris,  between  which  body  and  the  vaginal 
margin  a  smooth  triangular  space  exists,  the  vestibule. 
At  the  junction  of  the  vagina  and  the  vestibule  the  urethra 
opens. 

Vaginal  examination. — Passing  along  the  posterior  vaginal 
wall  the  finger  enters  the  superior  fornix,  the  upper  part 
of  which  is  in  direct  relation  with  the  peritoneal  cavity 
(Douglas's  pouch).  Along  the  anterior  wall  the  smaller 
anterior  fornix  is  first  encountered,  this  cul-de-sac  not 
being  directly  related  to  the  peritoneal  cavity,  and  imme- 
diately above  this  the  as  uteri  may  be  examined.  Bi- 
manually,  much  information  can  usually  be  gained  with 
regard  to  the  size  and  position  of  the  uterus,  the  condition 
of  the  uterine  appendages,  the  contents  of  Douglas's 
pouch,  etc. 

(6)  The  rectal  area. — This  area  is  divided  into  two 
lateral  parts  by  a  line  drawn  from  the  "  central  point  of 
the  perineum  "  to  the  tip  of  the  coccyx,  and  the  examining 
fingers  may,  in  thin  subjects,  be  made  to  sink  deeply 
into   each    lateral    recess   (the   ischio-rectal  fossae),  being 


THE    ABDOMEN  69 

then  in  relation  with  the  rectum  and  levator  ani  muscle 
on  the  inner  side,  the  ischial  tuberosity  and  the  obturator 
internus  muscle  on  the  outer  side,  the  transverse  perinei 
muscle  in  front,  and  the  gluteus  maximus  and  great  sacro- 
sciatic  ligament  behind. 

Rectal  examination. —  If  the  forefinger  be  gently  inserted 
into  the  rectum,  definite  resistance  is  offered  by  the 
external  and  internal  sphincters,  the  latter  aided  by 
contraction  of  the  levator  ani  muscle  Further  on  the 
finger  enters  the  dilated  ampuUary  portion  of  the  rectum, 
meeting,  perhaps,  further  obstruction  from  Houston's 
valves.  When  insinuated  as  far  as  possible,  the  palmar 
aspect  of  the  distal  phalanx  will,  in  the  male,  be  in  contact 
with  the  vasa  deferentia  and  the  vesiculse  seminales,  the 
middle  phalanx  with  the  prostate  gland,  and  the  proximal 
phalanx  with  the  sphincters,  which  intervene  between  the 
finger  and  the  triangular  ligament  and  the  spongy  and 
membranous  parts  of  the  urethra.  Posteriorly,  the  hollow 
of  the  sacrum  and  the  coccyx  can  be  fully  explored.  It 
is  most  important  to  bear  in  mind  that  the  peritoneum 
is  reflected  from  the  rectum  on  to  the  upper  third  of  the 
vagina  in  the  female,  and  on  to  the  vesiculce  seminales, 
about  I  inch  above  the  upper  limit  of  the  prostate  gland,  in 
the  male. 

In  children,  since  the  true  pelvis  is  but  little  developed 
and  the  later  pelvic  viscera  are  practically  abdominal,  a 
rectal  examination  enables  one  to  explore  all  the  lower 
abdominal  viscera,  including  the  bladder. 


FIG.  XXI. 

1.  The  iliac  crest. 

2.  The  posterior  superior  iliac  spine. 

3.  The  sacrum. 

4.  The  second  sacral  spine. 

5.  The  coccyx. 

6.  The  pyriformis  muscle. 

7.  The  ischial  tuberosity. 

8.  The  sciatic  artery  and  the  ischial  spine. 

9.  The  great  trochanter  of  the  femur. 

10.  The  gluteal  artery. 

11.  Nelaton's  line. 

12.  The  great  sciatic  nerve. 

13.  The  internal  popliteal  nerve. 

14.  The  external  popliteal  nerve. 

15.  The  biceps  tendon. 

16.  The  semimembranosus  muscle. 

17.  The  semitendinosus  muscle. 

18.  The  outer  head  of  the  gastrocnemius  muscle. 

19.  The  inner  head  of  the  gastrocnemius  muscle. 

20.  The  posterior  tibial  artery  and  nerve. 

21.  The  external  saphenous  vein. 


THE  BACK  OF  THE  THIGH  AND  LEG 


no.  xxr. 


To  /are  f>.   70, 


FIG.  XXII. 

1.  The  iliac  crest. 

2.  The  pubic  spine. 

3-   Poupart's  ligament. 

4.  The  anterior  crural  nerve. 

5.  The  common  femoral  artery. 

6.  The  common  femoral  vein. 

7.  The  crural  canal. 

8.  The  superficial  femoral  artery. 

9.  Vastus  externus. 

10.  Vastus  internus. 

11.  The  upper  limit  of  the  synovial  membrane  of  the 

knee-joint. 

12.  The  patella. 

13.  The  ligamentum  patellae. 

14.  The  tubercle  of  the  tibia. 

15.  The  internal  tuberosity  of  the  tibia. 

16.  The  external  tuberosity  r>'"the  tibia. 

17.  The  head  of  the  fibula. 

18.  The  internal  saphenous  vein. 

19.  The  anterior  tibial  artery. 

20.  The  anterior  tibial  nerve. 

21.  The  musculo-cutaneous  nerve. 

22.  The  dorsalis  pedis  artery. 

23.  The  dorsal  venous  arch. 


THE  FRONT  OF  THE  THIGH  AND  LEG 


]'I(>.   XXII. 


To  follow  I'ig.  XXI. 


THE    LOWER    EXTREMITY  "  71 

which  becomes  less  marked  when,  as  the  result  of  disease 
or  disuse,  the  gluteus  maximus  undergoes  atrophic 
changes.  The  fold  of  the  nates  does  not  correspond  to 
Fig.  xxi.  *^^  ^°^^^  border  of  the  gluteus  maximus  muscle, 
as  it  crosses  almost  transversely  the  lower 
oblique  fibres  of  that  muscle.  This  fold  also  becomes  less 
distinct  when  the  glutei  muscles  degenerate.  The  head 
and  neck  of  the  femur  form  with  the  shaft  of  that  bone 
an  angle  of  125  to  130  degrees. 

Nelaton's  line.—"  If  in  the  normal  state  you  examine 
Fig.  xxi.,  11.  the  relation  of  the  great  trochanter  to  the  other 
'  5.  '""■'  bony  prominences  of  the  pelvis,  you  will  find 
that  the  top  of  the  great  trochanter  corresponds  to  a  line 
drawn  from  the  anterior  superior  iliac  spine  of  the  ilium 
to  the  most  prominent  point  of  the  tuberosity  of  the 
ischium.  This  line  also  runs  through  the  centre  of  the 
acetabulum.  The  extent  of  displacement  in  dislocation  or 
in  fracture  is  marked  by  the  projection  of  the  trochanter 
behind  and  above  this  line  "  (Nelaton). 

Bryant's  triangle. — When  the  patient  is  in  the  dorsal 
Fig.  xxiii.,    recumbent    position,  draw   a    line    round   the 

*  body   at    the    level   of    the    anterior    superior 

iliac  spine,  and  from  this  line  drop  a  perpendicular  to  the 
top  of  the  great  trochanter.  To  complete  the  triangle, 
draw  a  line  from  the  anterior  superior  iliac  spine  to  the 
top  of  the  trochanter.  When  the  trochanter  is  displaced 
upwards  the  perpendicular  line  is  diminished  in  length  as 
compared  with  the  sound  side,  and  when  it  undergoes 
a  backward  displacement  the  spino-trochanteric  line  is 
relatively  increased  in  length. 

(6). — Anterior  and  internal  aspect.  The  lower  extremity 
is  demarcated  from  the  abdomen  by  a  well-marked  furrow, 
the  inguinal  groove.     This   corresponds  to  the  situation 


72  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

of  PouparVs  ligament,  the  recurved  lower  border  of  the 
obliquus  externus  abdominis  muscle.  This  ligament,  as 
it  passes  from  the  anterior  superior  iliac  spine  to  the 
pubic  spine  of  the  same  side,  forms  the  upper  boundary 
of  Scarpa's  triangle,  a  space  which  is  best  demonstrated 
Fig.  xxiv.,  when  the  thigh  is  flexed,  abducted,  and  everted. 
'  The  sartorius  muscle  is  then  thrown  into  action 

and  the  outer  boundary  of  the  space  so  shown.  If  the 
hand  be  now  placed  on  the  upper  and  inner  aspect  of 
the  thigh  and  the  limb  be  sharply  adducted,  a  rounded 
tendon  at  once  becomes  noticeable.  This  is  the  adductor 
longus,  which  forms  the  inner  boundary  of  Scarpa's  triangle. 

The  outwardly  directed  adductor  longus  and  the 
inwardly  curving  sartorius  converge  to  form  the  apex  of 
the  triangle. 

The  floor  of  the  space  is  formed  from  without  inwards 
by  the  iliacus,  psoas,  pectineus  and  adductor  longus 
muscles.  In  the  superficial  fascia  which  overlies  this 
region,  numerous  lymphatic  glands  are  situated,  and  it 
will  here  be  convenient  to  briefly  discuss  their  general 
arrangement.  The  superficial  lymphatic  glands  are  placed 
in  three  main  groups  : 

(i)  The  oblique  or  inguinal  glands,  running  parallel  to 
and  below  Poupart's  ligament,  and  draining  the  anterior 
aspect  of  the  abdomen  below  the  level  of  the  umbilicus, 
the  lower  half  of  the  side  and  back,  the  gluteal  region, 
and  the  upper  and  outer  part  of  the  thigh. 

(2)  The  vertical  or  femoral  glands,  running  with  the  long 
internal  saphenous  vein,  and  draining  the  greater  part  of 
the  inner  aspect  of  the  foot,  leg,  and  thigh. 

(3)  The  pubic  glands,  situated  below  and  external  to  the 
pubic  spine,  and  draining  mainly  the  external  genitals, 
perineum,  and  anus. 


THE    LOWER    EXTREMITY  73 

The  deep  fascia  presents  an  opening,  the  saphenous 
Fig.  xxii.,  8.  opening,  for  the  transmission  of  the  long 
ig.  XXIV.,  9.  saphenous  vein  to  the  common  femoral  vein. 
This  foramen  is  oval  in  shape,  being  i  inch  long  and  |  to 
f  inch  broad,  the  long  axis  vertical.  The  central  point 
of  the  opening  is  situated  i^  inches  below  and  i^-  inches 
external  to  the  pubic  spine. 

Beneath  the  deep  fascia  overlying  Scarpa's  triangle, 
certain  important  structures  are  situated,  such  as  the 
common,  superficial  femoral,  and  profunda  femoris 
arteries,  the  corresponding  veins,  and  the  anterior  crural 
nerve.  These  will  all  be  dealt  with  later,  the  femoral 
rmg  alone  needing  here  further  definition. 

The  femoral  ring,  through  which  a  femoral  hernia 
Fig.  xxii.,  7.  commonly  escapes  from  the  abdominal  cavity. 
Fig.  XXIV.,  8.  jjgg  ijgiow  the  inner  part  of  Poupart's  ligament, 
and  external  to  the  pubic  spine.  A  good  way  to  define  the 
ring  with  precision  is  that  recommended  by  Holden : 
"  Feel  for  the  pulsation  of  the  common  femoral  artery, 
allow  ^  inch  on  the  inner  side  for  the  femoral  vein,  then 
comes  the  femoral  ring."  The  crural  or  femoral  ring 
presents  the  following  boundaries :  To  the  inner  side  is 
Gimbernat's  ligament ;  to  the  outer  side  is  the  femoral 
vein ;  in  front  is  Poupart's  ligament ;  behind  is  the 
pectineus  muscle  and  the  horizontal  ramus  of  the  os 
pubis. 

Hunter's  canal,  a  more  or  less  triangular  muscular 
Fig.  xxiv.,  channel  for  the  transmission  of  the  superficial 
femoral  artery,  occupies  the  middle  third  of  the 
antero-internal  aspect  of  the  thigh.  During  forcible  con- 
traction of  the  thigh  muscles,  Scarpa's  triangle  may  be 
seen  to  be  continued  downwards  as  a  shallow  depression 
between  the  extensor  and  adductor  muscles,  this  furrow 


74  HUMAN    LANDMARKS    AND    SURFACE    MARKINGS 

corresponding  to  the  position  of  the  canal  in  question. 
The  anatomical  boundaries  of  the  canal  are  (i)  vastus 
internus  externally,  (2)  adductor  longus  and  magnus 
behind,  (3)  sartorius  and  a  strong  fascial  band  between 
the  adductors  and  vastus  internus  in  front  and  internal. 

The  canal  transmits  the  superficial  femoral  vein  and 
artery,  the  long  internus  saphenous  nerve  (anterior  crural), 
and  the  nerve  to  the  vastus  internus  (anterior  crural). 

In  order  to  compare  the  length  of  the  lower  extremities 
the  limbs  should  be  placed  parallel  to  one  another,  and 
the  tape-measure  carried  from  the  anterior  superior  iliac 
spine  to  the  tip  of  the  internal  malleolus  of  the  tibia  of 
Fig.  xxiv.,  the  same  side.  The  distance  between  these 
^®-  two  points  may  be  subdivided,  if  necessary,  by 

marking  out,  on  the  inner  aspect  of  the  knee,  the  trans- 
Fig,  xxiv.,     verse    line   which   indicates   the   level   of    the 
femoro-tibial  articulation.     The  lengths  of  the 
femur  and  of  the  tibia  are  thus  separately  estimated. 
The  region  of  the  knee. — The  biceps  tendon  forms  the 
upper   and   outer   boundary   of   the    popliteal 
space,  and  under  cover  of  this  tendon,  on  its 
inner  or  popliteal  aspect,  a  cord-like  structure  is  felt,  the 
external    popliteal    or    peroneal    nerve       This    intimate 
relation  of  tendon  and  of  nerve  must  be  remembered  in 
Fig.  xxi.,  14.  the  operation  of  tenotomy  of  the  biceps  tendon 
ig.  xxiii.,    .  j£  ^]^g  biceps  tendon  be  now  traced  downwards 
the  head  of  the  fibula  is  reached,  this  process  lying  below, 
external,  and  on  a  posterior  plane  to  the  outer  tuberosity 
of  the  tibia.     The  styloid  process  of  the  head 
of    the    fibula    projects    upwards    from     the 
posterior  part  of  the  head,  and  in  front  of  this  the  rounded 
long  external  lateral  ligament  of  the  knee-joint  can  be 
traced  upwards  to  its  femoral  attachment.     In  front  of 


FIG.  XXIII. 

1.  The  iliac  crest. 

2.  The  anterior  superior  iliac  spine. 

3.  Poupart's  ligament. 

4.  Bryant's  triangle. 

5.  Nelaton's  line. 

6.  The  great  trochanter. 

7.  The  ilio-tibial  band. 

8.  The  outer  tibial  tuberosity. 

9.  The  head  of  the  fibula. 

10.  The  biceps  tendon. 

11.  The  peroneal  nerve. 

12.  12.  The  anterior  tibial  nerve. 

13.  The  musculo-cutaneous  nerve. 

14.  14.  The  anterior  tibial  artery. 

15.  The  dorsalis  pedis  artery. 

16.  The  external  saphenous  vein. 

17.  The  venous  arch. 


THE  SIDE  OF  THE  THIGH  AND  LEG 


riG.  XXIII. 

To  /ace  /.  74. 


FIG.  XX I V. 

1.  The  anterior  superior  iliac  spine. 

2.  The  pubic  spines. 

3.  The  sartorius  muscle. 

4.  The  adductor  longus  muscle, 

5.  The  anterior  crural  nerve. 

6.  The  common  femoral  artery. 

7.  The  common  femoral  vein. 

8.  The  femoral  ring. 

9.  The  saphenous  opening. 

10.  10,  10.  The  internal  or  long  saphenous  vein. 

1 1 .  The  profunda  femoris  artery. 

12.  The  superficial  femoral  in  Scarpa's  triangle. 

13.  The  superficial  femoral  in  Hunter's  canal. 

14.  The  adductor  magnus  tendon. 

15.  The  adductor  tubercle. 

16.  The  lower  epiphysial  line  of  the  femtir. 

17.  The  line  of  the  knee-joint. 

18.  The  gracilis,  sartorius,  and  semitendinosus 

muscles. 

19.  The  internal  saphenous  nerve. 

20.  The  posterior  tibial  artery. 

21.  The  internal  plantar  artery. 

22.  The  external  plantar  artery. 

23.  The  anterior  tibial  nerve. 


THE  SIDE  OF  THE  THIGH  AND  LEG 


I'IG.  XXIV. 

To  follow  Fig.  XXI 1 1 


THE    LOWER   EXTREMITY 


75 


the  biceps  tendon  there  is  a  depression  which  is  bounded 

anteriorly  by  the  broad  iHo-tibial  band.  Two 
Fig.  XXIII.,  7. 

well-marked  tendons  bound  the  popliteal  space 
on  the  upper  and  inner  side,  the  semimembranosus  and 
semitendinosus.  The  latter  is  the  more  external,  the 
Fig.  xxi.,       more   superficial,  and  the  narrower,  and  the 

'^'  '^-  long  rounded  tendon  can  be  traced  some 
distance  up  into  the  thigh.  The  semimembranosus 
tendon  lies  to  the  inner  side  of  the  semitendinosus  and 
on  a  deeper  plane.  The  broad  tendon  can  be  traced 
downwards  to  its  insertion  into  the  inner  and  posterior 
aspect  of  the  internal  tuberosity  of  the  tibia.  On  the 
inner  aspect  of  the  knee  the  tendon  of  the  gracilis  muscle 
and  the  lower  part  of  the  sartorius  muscle  form  a  fairly 
well-marked  prominence,  the  individual  muscles  being, 
however,  usually  incapable  of  clear  definition  owing  to 
their  flattened  shape.  Between  these  tendons  and  the 
prominent  vastus  internus  muscle  a  depression  exists,  and 
Fig.  xxi  v.,  by  deep  palpation  the  adductor  magnus  tendon 
may  be  felt  lying  under  cover  of  the  inner 
margin  of  the  vastus  internus  muscle.  By  tracing  this 
Fig.  xxiv.,  tendon  downwards  to  its  insertion  the  adductor 
Fie  xxiv      i'^ibercle  is  reached.     This  tubercle  corresponds 

'^-  also  to  the  level  of  the  lower  epiphysial  line  of 

the  femur. 

The  sartorius  and  gracilis  muscles,  though  not  easily 
defined  on  the  inner  side  of  the  knee,  form,  together  with 
Fig  xxiv      the  semitendinosus  muscle,  a  fairly  well-marked 

'®-  elevation  below  the  internal  tuberosity  of  the 

tibia,  which  is  directed  downwards,  forwards,  and  outwards. 

The  ligamentum  patellae  narrows  off  as  it  passes  from 
Fig.  xxii.,      the  inferior  border  of  the  patella  to  the  tibial 

'^-  tuberosity,  and  on  each  side  of  the  ligament 


76  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

depressions  exist,  in  the  lower  part  of  which  the  inner  and 
outer  tuberosities  of  the  tibia  are  readily  felt. 

The  prepatellar  bursa  extends  from  the  middle  of  the 
patella  to  the  tibial  tubercle.  Laterally,  the  bursa  falls 
just  short  of  the  patellar  border. 

The  synovial  membrane  of  the  knee-joint  extends  upwards 
Fig.  xxii.,  about  three  fingers'  breadth  above  the  upper 
border  of  the  patella  when  the  leg  is  in  the 
extended  position,  reaching  up  under  the  vastus  internus 
to  a  slightly  higher  level  than  on  the  other  side.  Laterally, 
the  synovial  membrane  extends  to  near  the  inner  and 
outer  margins  of  the  femoral  condyles,  whilst  the  lower 
limit  is  situated  just  above  the  tubercle  of  the  tibia. 
When  the  joint  is  distended  with  fluid  the  outline  of  the 
joint  cavity  becomes  marked,  and  the  depressions  which 
normally  exist  each  side  of  the  patellar  ligament  become 
obliterated. 

The  ankle  and  foot. — The  external  malleolus  projects 
Fig.  xxvii.     about  I  inch  below  the  internal,  and  also  lies 

''  ^"  on  a  more  posterior  plane.      The  ankle-joint 

corresponds  in  level  to  a  point  about  ^  inch  above  the 
tip  of  the  internal  malleolus. 

About  I  inch  below  and  ^  inch  in  front  of  the  styloid 
process  of  the  external  malleolus  is  the  peroneal  tubercle, 
Fig.  XXV.      which  separates  the  peroneus  brevis  above  from 

^^'  the  longus  below.      The  two  peronei  tendons, 

when  traced  upwards,  are  found  to  pass  behind  the 
external  malleolus.  About  i  inch  in  front  of  the  peroneal 
cubercle  is  the  prominent  styloid  process  of  the  base  of 
Fig.  XXV.,     the  fifth  metatarsal  bone,  to  which  the  pero- 

'^-  neus  brevis  is  attached.     Between  the  peroneal 

tubercle  and  the  base  of  the  fifth  metatarsal  bone  the 
cuboid  bone  may  be  felt,  grooved  on  its  outer  and  under 


FIG.  XXV. 

Internal  Aspect  of  Foot  and  Anki;,e. 

1.  The  tibialis  anticus. 

2.  The  internal  malleolus. 

3.  The  tibialis  posticus. 

4.  The  tubercle  of  the  scaphoid. 

5.  The  flexor  longus  digitorum. 

6.  The  sustentaculum  tali  of  the  os  calcis. 

7.  The  flexor  longus  hallucis. 

8.  The  tendo  Achillis. 

9.  The  head  of  the  astragalus. 

10.  The  joint  between  the  scaphoid  and  the  internal  cuneiform. 

11.  The  joint  between  the  first  metatarsal  bone  and  the  internal 

cuneiform. 

12.  The  metatarso-phalangeal  joint. 

External  Aspect  ok  Foot  and  Ankle. 

13.  The  external  malleolus. 

14.  The  head  of  the  astragalus. 

15.  The  head  of  the  os  calcis. 

16.  The  peroneus  tertius. 

17.  The  base  of  the  fifth  metatarsal  bone. 

18.  The  peroneus  brevis. 

19.  The  peroneus  longus. 

20.  The  peroneal  tubercle  of  the  os  calcis. 

21.  The  tendo  Achillis. 

22.  The  extensor  longus  digitorum. 


H 
O 
O 

Q 

< 
< 


o 

»— I 

o 


/ 


THE    LOWER   EXTREMITY  77 

aspect    by   the    peroneus    longus    tendon.     The    tendon 

crosses  the  plantar  aspect  of  the  foot  in  a  forward  and 

inward  direction,  to  be  inserted  into  the  outer  aspect  of  the 

base  of  the  first  metatarsal  bone.     Immediately  in  front  of 

the  external  malleolus  there  is  a  well-marked 
FisT   XXV  . 

depression,  which    is   bounded   in    front   by  a 

prominence  due  to  the  fleshy  mass  of  the  extensor  brevis 

digitorum,  and   above    by   the   tendon    of    the    peroneus 

tertius. 

If  the  floor  of  this  depression  be  examined. 
Fist.  XXV    14 

'     '  the  head  of  the  astragalus  will  be  felt  above  and 

to  the  inner  side,  and  the  head  of  the  os  calcis 

'     ■  below  and  to  the  outer  side. 

Between  the  two  malleoli  in  front  of  the  ankle-joint 

four  tendons  can  be  felt.     The  most  prominent  and  the 

innermost  is  the  tendon  of  the  tibialis  anticus 

'^  ^     '  ■  muscle.     External  to  this   follow  the  extensor 

longus  hallucis,  the  extensor  longus  digitorum 

'^'  ^^^       and  the  peroneus  tertius.     When  the  foot   is 

well  extended,  the   head  of   the   astragalus   can  also  be 

identified  lying  under  cover  of  the  extensor  tendons. 

Immediately  below  the  internal  malleolus  is  the  susten- 

pj     j^^y  ^  Q  taculum  tali,  grooved  on  its  under  aspect  by  the 

Fig.  XXV.,  7.  flgxor  longus  hallucis  tendon,  and  between  the 

Fig  XXV ,      sustentaculum  and  the   internal  malleolus  the 

^'  ^-  tibialis    posticus   and   flexor   longus   digitorum 

pass. 

The  tibialis    posticus   tendon    can    be  traced   upwards 

behind  the  internal  malleolus  and  downwards 

Fig.  XXV.,  3.  ^^  ^^^  scaphoid  tuberosity,  to  which  process 

the   tendon   gains    its    main    attachment.      In 

Fig.  XXV.,  4.   ^^^^^  ^^  ^^^  internal  malleolus  there  is  another 

depression,   which    lies    below   the    line    of    the    tibialis 

7-2 


78  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

anticus  tendon,  and  here  the  head  of  the  astragalus  can 

again    be  felt,  especially  prominent  when  the 

Fig.  XXV.,  1.  £qq^    jg   ^g|2    everted.     About    i    inch    below 

Fig.  XXV.,  9.  and  in  front  of  the  internal  malleolus  the 
Fie  XXV  4  tuberosity  of  the  scaphoid  bone  forms  the 
most  prominent  bony  point  on  the  inner  side 
of  the  foot,  and  a  line  which  joins  the  tip  of  the  internal 
malleolus,  the  head  of  the  astragalus,  and  the  scaphoid 
tubercle,  normally  presents  a  slight  upward  convexity. 

In  flat-foot,  the  head  of  the  astragalus  undergoes  a 
downward  displacement,  and  the  line  uniting  the  three 
bony  points  becomes  straight,  or  even  downwardly 
convex. 

A  line  drawn  almost  transversely  across  the  foot  from 

a  point  just  behind  the  scaphoid  tubercle  indicates  the 

level  of  the  mid-tar  sal  joint. 

Fig.  XXV.,  Ij^  front  of  the  scaphoid  tuberosity,  the  in- 

_.^°'  ^^"         ternal  cuneiform  and  the  first  metatarsal  bones 
Fig.  XXV,, 

'''  ^2-         may  be  located  and  verified. 
Behind   the   ankle-joint,  the  tendo  Achillis  is  placed, 
Pior  vvx/       the  tendon  being  at  its  narrowest  at  a  point 

r  ig.  XXV., 

^'  ^'-  about  i^  inches  above  its  insertion  into  the 
posterior  part  of  the  os  calcis.  When  distended  with 
fluid,  the  synovial  membrane  of  the  ankle-joint  bulges 
outwards,  so  as  to  obliterate  the  depressions  that  normally 
lie  between  the  tendo  Achillis  and  the  two  malleoli. 

The  anterior  annular  ligament  of  the  ankle. — The  upper 

portion  of  this  ligament,  about  i  inch  broad, 

ig.  XXVI.,    .  gj^^gj^^g   transversely   across    the    ankle    from 

tibia   to   fibula.      It    presents    two    compartments    only, 

one    for    the    tibialis    anticus,    and    one    for 

Ig.  XXVI.,    .  ^j^^  remaining  extensor  tendons.     The  former 

tendon  alone  possesses  a  synovial  sheath. 


THE  REGION  OF  THE  ANKLE  AND  FOOT 


FIG.  XX VI. 

1.  The  internal  malleolus. 

2.  The  external  uialleoliis. 

3.  The  transverse  band  of  the  anterior  annular  li,<(anient. 

4.  The  Y-shaped  band  of  the  anterior  annular  ligament. 

5.  The  head  of  the  os  caicis  and  the  extensor  brevis  digitorum. 

6.  The  tibialis  anticus  synovial  sheath. 

7.  The  extensor  longus  hallucis  synovial  sheath. 

8.  The    exten.sor    longus   digitorum    and    peroneus   tertius 

synovial  sheath. 

To /ace  />.  78. 


THE  REGION  OF  THE  ANKLE  AND  FOOT 


FIG.  XXVII. 

1.  The  transverse  band. 

2,  3.  The  upper  and  lower  hml  s  of  the  Y-shaped  part  of  the 

anterior  annular  ligament. 

4.  The  tibialis  anticus  synovial  sheath. 

5.  The  internal  malleolus. 

6.  The  internal  annular  ligament. 

7.  The  tibialis  posticus  synovial  sheath. 

S.  The  flexus  longus  digitoruni  synovial  sheath. 
9.  The  flexor  longus  hallucis  synovial  sheath. 

To  face  p.  79. 


THE    LOWER   EXTREMITY  79 

The  lower  portion  of  the  ligament  is  Y-shaped,  the 
Fig.  xxvi.,4.  single  limb  arising  from  the  upper  and  outer 
ig.  XXVI.,  5.  aspect  of  the  head  of  the  os  calcis  in  close 
connection  with  the  origin  of  the  extensor  brevis  digitorum 
muscle.  The  upper  limb  of  the  divided  portion  becomes 
attached  to  the  internal  malleolus,  whilst  the  lower  limb 
sweeps  over  to  the  scaphoid  tuberosity  and  to  the  inner 
side  of  the  foot.  The  extensor  communis  digitorum  and 
Fig.  xxvi.,    the    peroneus    tertius    pass    under    the    single 

go 

'  ■  undivided  limb,  and  possess  in  this  situation 
a  common  synovial  sheath ;  whilst  the  extensor  longus 
Fig.  xxvi ,  hallucis  and  the  tibialis  anticus  pass  through 
separate  compartments  in  each  limb  of  the 
divided  portion  of  the  ligament,  and  each  tendon  in  so 
doing  is  surrounded  by  a  synovial  sheath,  that  enveloping 
the  tibialis  anticus  tendon  being  continuous  with  the 
sheath  already  alluded  to  as  enclosing  the  tendon  under 
the  transverse  portion  of  the  ligament. 

The  internal  annular  ligament  is  triangular  in  shape,  the 
Fig  xxvii      apex  being  attached  to  the  internal  malleolus, 

®'  and  the  base  to  the  lower  margin  of  the  os 

calcis.  From  the  deep  aspect  of  the  ligament  septa  are 
given  off  which  form  separate  compartments  for  the 
Fig.  xxvii.,  passage  of  the  tendons  of  the  tibialis  posticus, 
^'  ^'  ^  flexor  longus  digitorum,  and  flexor  longus 
hallucis  muscles,  each  tendon  having  its  own  synovial 
sheath.  These  three  sheaths  extend  for  about  i  inch 
above  the  upper  limit  of  the  annular  ligament;  and 
although  the  sheath  enveloping  the  tibialis  posticus 
reaches  almost  as  far  forwards  as  the  scaphoid  tuberosity, 
the  other  two  sheaths  usually  terminate  about  ^  inch 
p.  below   the    inferior    margin   of   the    ligament. 

3,  3, 3, 3.    Thg   flexor  longus   hallucis   and   flexor  longus 


8o  HUMAN   LANDMARKS   AND   StlRfACE   MARKINGS 

digitorum  have,  again,  distinct  synovial  sheaths  just  before 
their  insertion  into  the  distal  phalanges  of  the  toes,  these 
sheaths,  however,  being  very  variable,  and  rarely  extending 
further  backwards  than  the  heads  of  the  metatarsal  bones. 
The  external  annular  ligament  is  less  definite  in  shape, 
and  can  only  be  described  as  a  broad  band  passing  from 
the  external  malleolus  to  the  lower  margin  of  the  os  calcis. 
Fig.  xxviii.,  Beneath  it  two  tendons  pass,  the  peroneus 
'  ^'  longus  and  brevis.     These  two  tendons  possess 

a  common  synovial  sheath,  which  extends  upwards  2  to 
3  inches  above  the  tip  of  the  external  malleolus,  and 
downwards  as  far  as  the  "  peroneal  tubercle,"  where  the 
sac  divides  into  two,  one  part  accompanying  the  peroneus 
brevis  to  near  the  base  of  the  fifth  metatarsal  bone,  the 
other  extending  forwards  to  the  outer  and  under  aspect  of 
the  cuboid  bone.  The  peroneus  longus  is  also  usually 
enclosed  in  a  synovial  sheath  in  the  last  inch  or  so  of  its 
course,  previous  to  its  insertion  into  the  outer  aspect  of 
the  base  of  the  first  metatarsal  bone. 


The  Vessels  and  Nerves  of  the  Lower 
Extremity. 

The  gluteal  artery  emerges  from  the  great  sacro-sciatic 

notch,  above   the    pyriformis   muscle,   at   the 

''     '  junction  of  the  inner  and  middle  thirds  of  a 

line  drawn  from  the  posterior  superior  iliac  spine  to  the 

top  of  the  great  trochanter  of  the  femur  of  the  same  side. 

The  sciatic  artery  may  be  ligatured  at  a  point  which  lies 

just  external  to  the  junction  of  the  middle  and 

ig.  XXI.,    .    jQ.^gj.  ^]-ii]-ds  of  a  line  drawn  from  the  posterior 

superior   iliac    spine   to    the    outer    part    of    the    ischial 

tuberosity  of  the  same  side.      This  line  also  cuts  across 


1^     5  n  o 


X         2 

"T;      (U 
03     tfi 

OJ 

y^ 

c/]    •— ' 

d       S  >- 

II 

en     (T. 

o  ^ 

3    !^ 

be  S 

r2     "5 

^        D   ^ 

6 

f/i    -t-» 

3  1^ 

if!       ■J'l 

!/■;    ^_ 

ij  <*. 

be  o 

c 

P    rt 

>   o 

"5  — 

(/I 

§  2 

ttJ     V 
O    O 

c3     oj 

>-    ^ 

;-<    u 

t-    Jll 

"5  i1 

oj    aj 

<U     V 

-M     </) 

Ji       <U 

1-1 

a  Ph 

P.  P. 

(Li     OJ 

5  ii 

V 

(U     OJ 

i>     (U 

^    -15 

"3     r5 

•*-* 

.«  ^ 

H  H 

H 

H  H  H  H 

-t    I/O  yD     I  - 


THE    LOWER   EXTREMITY  8l 

the  posterior  inferior  iliac  spine  and  the  tip  of  the  ischial 
spine,  whilst  the  internal  pudic  artery  hes  immediately 
internal  to  the  seat  of  election  for  ligation  of  the  sciatic 
artery. 

The  common  and  superficial  femoral  arteries. — With  the 
thigh  flexed,  everted,  and  slightly  abducted, 
these  vessels  correspond  in  direction  to  a  line 
drawn  from  a  point  midway  between  the  anterior  superior 
iliac  spine  and  the  symphysis  pubis  to  the  adductor 
tubercle  of  the  femur  below. 
Fig.  xxiv.,        The  upper  i^  inches  of  this  line  =  the  common 

^'  femoral  artery, 

pj     j^j^jy  The   upper  third  =  the   common   and  super- 

^>  '2.         ficial  femoral  arteries  in  Scarpa's  triangle. 
Fig  xxiv  The  upper  two-thirds  =  the  complete  common 

6, 12, 13.     and  superficial  femoral  arteries. 
Fio-  vviv  The   middle   third  =  the    superficial   femoral 

'3-  artery  in  Hunter's  canal. 

The  popliteal  artery  enters  the  upper  angle  of  the 
popliteal  space  (from  the  inner  side)  by  passing  between 
the  femur  and  the  adductor  magnus  tendon.  The  vessel 
at  first  passes  obliquely  outwards  and  downwards  to  the 
mid-point  of  the  space,  and  then  changes  direction  by 
passing  vertically  downwards  as  far  as  the  lower  border 
of  the  popliteus  muscle,  at  which  level  it  bifurcates  into 
anterior  and  posterior  tibial  arteries.  The  point  of  bifur- 
cation corresponds  to  the  level  of  the  tubercle  of  the  tibia. 

The  anterior  tibial  artery. — The  course  of  this  vessel 
Fig.  xxii.,  "i^'Y  be  indicated  by  a  line  drawn  from  a  point 
Fig^xxiii  i^s^  below  the  level  of  the  tibial  tubercle,  and 
14, 14.  midway  between  "the  outer  tuberosity  of  the 
tibia  and  the  head  of  the  fibula,  to  a  second  point  in  front 
of  the  ankle  midway  between  the  two  malleoli,  at  which 


82  HUMAN    LANDMARKS   AND    SURFACE    MARKINGS 

level  the  artery  lies  between  the  tendons  of  the  extensor 
longus  hallucis  and  longus  digitorum  muscles. 
Fig.  xxii.  The  anterior  tibial  artery  is  continued  on- 

pj     j^'j^jjj      wards  as  the  dorsalis  pedis  as  far  as  the  base  of 
the  first  interosseous  space. 
The  posterior  tibial  artery  starts  at  the  lower  border  of 
Fig.  xxi.,      the  popliteus   muscle  as  one  of   the  terminal 
branches   of   the   popliteal   artery.     It  can    be 
represented  by  a  line  which  starts  at  the  inferior  angle  of 
the  popliteal  space,  on  a  level  with  the  tubercle  of  the 
tibia,  and  which  passes  downwards  and  inwards  to  the 
mid-point  between  the  posterior  border  of  the  internal 
malleolus  and  the  inner  border  of  the  os  calcis.     At  this 
level   it   lies   under  cover   of   the   internal   annular  liga- 
ment, and  bifurcates  in  this  situation  into  the  internal  and 
Fig.  xxiv.,    external  plantar  arteries.     Behind  the  internal 
20  22.       malleolus  the  posterior  tibial  artery  lies  between 
the  tendons  of  the  flexor  longus  hallucis  and  longus  digi- 
torum muscles,  but  on  a  slightly  superficial  plane. 

The    internal   plantar    artery   passes    forwards    to    the 
cleft  between  the  first  and  second  toes,  whilst 
'    '  the  more  important  external  plantar  artery  is 
first  directed  forwards  and  outwards  towards  the  base  of 
the  fifth  metatarsal  bone,  and  then,  changing  direction, 
passes  forwards  and  inwards  to  the  base  of  the 
ig.  xxix.,  .  ^^^^  interosseous  space,  forming  in  this  latter 
part  of  its  course  the  deep  plantar  arch.     It  anastomoses 
with  the  dorsalis  pedis  artery,  which  dips  downwards  be- 
tween the  two  heads  of  the  first  dorsal  interosseous  muscle. 
The  external  saphenous  vein  arises  from  the  outer  side  of 
Fig.  xxiii.,    the  venous   arch  on  the   dorsum  of   the  foot, 
'^'  ^^'        passing  upwards  behind  the  external  malleolus 
and  along  the  outer  and  back  part  of  the  leg  to  the  middle 


THE   LOWER   EXTREMITY  83 

of  the  popliteal  space,  where  it  pierces  the  deep  fascia  to 
Fig.  xxi.,  open  into  the  popliteal  vein.  It  is  accompanied 
in  the  greater  part  of  its  course  by  the  external 
saphenous  nerve,  which  extends  forwards  on  the  outer  side 
of  the  foot  as  far  as  the  tip  of  the  little  toe. 

The  internal  saphenous  vein  arises  from  the  inner  side  of 
Fig.  xxiv.,  the  venous  arch  found  on  the  dorsum  of  the 
'  '  ^  foot.  It  passes  upwards  in  front  of  the  internal 
malleolus,  along  the  inner  side  of  the  leg  and  knee,  behind 
the  internal  condyle  of  the  femur,  and  its  further  upward 
course  in  the  thigh  is  indicated  by  a  Ime  drawn  from  the 
adductor  tubercle  to  the  saphenous  opening.  Attention 
has  previously  been  drawn  to  the  elevation  below  the 
internal  tuberosity  of  the  tibia  which  is  formed  by  the 
sartorius,  gracilis  and  semitendinosus  muscles,  and  below 
this  prominence  the  saphenous  vein  is  accompanied  by 
the  internal  saphenous  nerve,  a  branch  of  the  deep  division 
of  the  anterior  crural.  The  saphenous  nerve  runs  down 
the  leg  with  the  vein,  in  front  of  the  internal  malleolus  of 
Fig  xxiv  t^^  tibia,  and  extends  as  far  forwards  as  the 
^^  ball  of  the  great-toe.     In  the  thigh  the  nerve 

crosses  in  front  of  the  superficial  femoral  artery  from  with- 
out inwards,  and  accompanies  that  artery  throughout  the 
whole  length  of  Hunter's  canal. 

The  anterior  crtiral  nerve  emerges  from  under  cover  of 

Poupart's   ligament,    about    half-way   between 

ig.  xxiv.,    .  ^j^^  anterior  superior  iliac  spine  and  the  pubic 

spine.      The    nerve   lies    nearly   ^    inch    external   to   the 

common  femoral  artery,  and  the  same  distance  external 

to  the  femoral  sheath. 

The  great  sciatic  nerve  makes  its  exit  from  the  pelvis 

through  the   great    sacro-sciatic   notch   below 

'6  XX'- >       ^j^g   pyriformis    muscle.     The   nerve   emerges 


04  HUMAN    LANDMARKS   AND    SURFACE  MARKINGS 

from  under  cover  of  the  lower  border  of  the  gluteus 
maximus  muscle  just  to  the  inner  side  of  the  mid-point 
between  the  ischial  tuberosity  and  the  great  trochanter 
of  the  femur.  The  nerve  corresponds  in  direction  to  the 
upper  two-thirds  of  a  line  drawn  downwards  from  the 
above  point  to  the  middle  of  the  popliteal  space  below. 
At  the  junction  of  the  middle  and  lower  thirds  of  the 
thigh  the  great  sciatic  nerve  divides  into  its  two  terminal 
branches,  internal  and  external  popliteal. 

The  small  sciatic  nerve  lies  in  the  same  line  as  the  great 
sciatic,  but  extends  downwards  as  far  as  the  inferior  angle 
of  the  popliteal  space. 

The  internal  popliteal  nerve  crosses  the  popliteal  artery 

superficially  from  without  inwards ;  its  onward 

"  continuation,  the  posterior  tibial  nerve,  and  the 

two  terminal  branches  of  the  posterior  tibial  nerve,  the 

internal  and  external  plantars,  all  have  the  same  surface 

marking  as  the  corresponding  arteries.     Two 
Fiff.  xxi    20 

''      '  points,  however,  need  to  be  borne   in   mmd : 

first,  the  posterior  tibial  nerve  crosses  the  corresponding 

artery  superficially  from  within  outwards  and  downwards 

and,   secondly,   the   internal   plantar   nerve   is   relatively 

much  more  important  than  the  corresponding  artery. 

The  external  popliteal  or  peroneal  nerve  was  last  seen  to  lie 
Fig.  xxi.,  under  cover  of  the  biceps  femoris  tendon  at  the 
Fie'  xxiii      upper  and  outer  boundary  of  the  popliteal  space. 

10.,  11.  'pjjg  nerve  follows  the  tendon  downwards  to  the 
head  of  the  fibula,  and  curls  round  to  the  antero- external 
Fie;  xxiii.     aspect  of  the  leg  about  I  inch  below  the  head 

12, 13.  q{  ^]^g^^  bone,  dividing  there  into  its  two  ter- 
minal branches,  anterior  tibial  and  musculo-cutaneous. 

The  anterior  tibial  nerve  passes  downwards  and  inwards 
to  join  the   corresponding  artery,  lying  external  to  the 


THE    LOWER   EXTREMITY  85 

upper  third  of  the  artery,  superficial  to  the  middle  third, 
Fig.  xxii.,     ^^^  external  again  to  the  lower  third.      The 

^°"  nerve   extends   forwards   along  the   outer  side 

Fig.  xxiii.,  ^^  ^^^  dorsalis  pedis  artery  as  far  as  the  cleft 
between  the  first  and  second  toes,  the  con- 
tiguous sides  of  which  toes  it  supplies. 

The  nmsctilo-cutaneous  nerve,  running  down  in  the  sub- 
Fig,  xxii.,  stance  of  the  peronei  muscles,  becomes  cuta- 
pj  j^j^jjj  neous  below  the  middle  of  the  leg.  It  then 
^^  passes  obliquely  downwards  and  inwards  across 

the  anterior  annular  ligament,  to  be  distributed  to  the 
greater  part  of  the  dorsum  of  the  foot. 


APPENDIX 

THE  LENGTH  OF  VARIOUS  PASSAGES, 
TUBES,  ETC. 

The  spinal  cord,  i6  to  i8  inches. 

The  trachea,  4^  inches. 

The  right  bronchus,  i  inch. 

The  left  bronchus,  i|  to  2  inches. 

The  pharynx,  4I  inches. 

The  oesophagus,  g  to  10  inches.* 

The  stomach  : 

Capacity,  about  2  pints. 

Length,  10  inches. 

Width,  4  to  5  inches. 
Duodenum,  8  to  10  inches. 
Bile-duct,  3  inches. 
Small  intestine,  23  feet. 

Jejunum,  upper  two-fifths. 

Ileum,  lower  three-fifths. 
Appendix,  3  to  4  inches. 
Caecum,  2|  inches. 
Ascending  colon,  8  inches. 
Transverse  colon,  20  inches. 
Descending  colon,  4  to  6  inches. 

*  The  distance  from  the  teeth  to  the  cardiac  orifice  of  the  stomach 
is  about  16  to  17  inches. 

86 


APPENDIX 

Iliac  colon,  5  to  6  inches. 

Pelvic  colon,  16  to  18  inches. 

Rectum,  5  to  6  inches. 

Anal  canal,  i  to  ij  inches. 

Crural  canal,  ^  inch. 

Inguinal  canal,  i|-  inches. 

Receptaculum  chyli,  i  to  2  inches. 

Thoracic  duct,  16  to  18  inches. 

Kidney,  4^  inches  by  2^  inches  by  i^  inches. 

Ureter,  10  inches. 
Male  urethra,  8  to  10  inches. 
Prostatic,  i  to  li  inches. 
Membranpus,  anterior  wall,  |  inch. 
„  posterior  wall,  |  inch. 

Spongy  and  penile,  6  to  8  inches. 
Testis,  ii  inches  by  i  inch  by  f  inch. 
Seminiferous  tubules,  2  to  3  feet. 
Canal  of  the  epididymis,  ig  to  20  feet. 
Vas  deferens,  16  to  18  inches. 
Ovary,  i  inch  by  |  inch. 
Fallopian  tubes,  4  to  4^  inches. 
Uterus,  3  inches  by  2  inches  by  i  inch. 
Vagina,  anterior  wall,  3  inches. 
,,        posterior  wall,  4  inches. 
Female  urethra,  i  to  i|  inches. 


87 


APPENDIX 


THE  WEIGHT  OF  SOME  ORGANS. 

The  brain  :  Male,  50  ounces  ;  female,  45  ounces. 

The  lungs  :  Together,  42  ounces  ;  right,  22  ounces ; 
left,  20  ounces. 

The  heart :  Male,  10  to  12  ounces ;  female,  8  to 
10  ounces. 

The  liver,  50  to  60  ounces. 

The  kidneys,  4I  ounces. 

The  suprarenals,  i  to  2  drachms. 

The  prostate,  6  drachms. 

The  testis,  6  to  8  drachms. 

The  ovary,  i  to  2  drachms. 

The  spinal  cord,  i|  ounces. 

The  pancreas,  2  to  4  ounces. 

The  spleen,  7  ounces. 


APPENDIX  89 


THE   OSSIFICATION   AND   EPIPHYSES   OF  THE    BONES 
OF  THE  UPPER  AND  LOWER  EXTREMITIES. 

Certain  epiphyses  and  epiphysial  Hnes  have  been  alluded  to  in  the 
text,  and  the  following  table,  compiled  from  Gray's  "  Anatomy,"  has 
consequently  been  appended  • 
(a)  The  Upper  Extremity  ; 
T/ie  clavicle : 

I  centre  for  the  shaft  (in  membrane)  in  the  fourth  to  fifth 

week  (i.u.l.).* 
I  centre  for  the  sternal  end  in  the  eighteenth  to  twentieth 
year. 

Union  between  the  two  in  the  twenty-fifth  year. 
TAe  scapula : 

I  centre  for  the  body  in  the  eighth  week  (i.u.l.). 
I  centre  for  the  coracoid  process  in  the  first  year. 

1  centre  for  the  base  of  the  coracoid\ 

process  I  between  the  fifteenth 

2  centres  for  the  acromial  process  y      and  eighteenth 
I  centre  for  the  vertebral  border  years. 

I  centre  for  the  inferior  angle 
Tkc  humerus : 

I  centre  for  the  shaft  in  the  eighth  week  (i.u.l.). 
I  centre  for  the  head  in  the  first  year. 
I  centre  for  the  great  tuberosity  in  the  third  year. 
1  centre  for  the  small  tuterosity  in  the  fourth  year. 

Head  and  tuberosities  unite  together  in  the  fifth  year' 

and  with  the  shaft  in  the  twentieth  year. 
I  centre  for  the  internal  condyle  in  the  fifth  year. 
1  centre  for  the  trochlear  in  the  twelfth  year. 
I  centre  for  the  capitellum  in  the  second  year. 
I  centre  for  the  external  condyle  in  the  thirteenth  year. 
The  last  three  unite  together  to  form  an  epiphysis, 

which  unites  with  the  shaft  in  the  seventeenth  year, 

the  internal  condylejoining  separately  in  the  eighteenth 

year. 
The  radius  and  ulna : 

I  centre  for  the  shaft  of  the  radius  in  the  eighth  week 

(i.u.l.). 
I   centre  for  the  shaft  of  the  ulna  in  the  eighth  week 

(i.u.l.). 

*  i.u.l.  =  intra-uterine  life. 


go  APPENDIX 

I  centre  for  the  lower  end  of  the  radius  in  the  second  year 

— union  at  twenty. 
I  centre  for  the  lower  end  of  the  ulna  in  the  fourth  year — 

union  at  twenty. 
I  centre  for  the  upper  end  of  the  radius  in  the  fifth  year — 

union  at  sixteen. 
I  centre  for  the  upper  end  of  the  ulna  in  the  tenth  year — 
union  at  sixteen. 
The  carpus : 

All  the  bones  are  cartilaginous  at  birth.     The  first  centre 
of  ossification  appears  in  the  os  magnum  and  the  last 
in  the  pisiform. 
T/ie  metacarpus  and  phalanges : 

I  centre  for  the  shaft  of  the  metacarpal  and  the  shaft  of 

the  phalanx  in  the  eighth  week  (i.u.L). 
I  centre  for  the  head  of  the  metacarpal  bone  and  the  base 
of  the  phalanx  in  the  third  year. 

Union   between   diaphyses    and    epiphyses   in   the 
twentieth  year. 

The  thumb  metacarpal  is  an  exception  to  the  rule,  a 
well-marked  epiphysis  always  appearing  at  the  base. 
This  bone,  therefore,  resembles  a  phalanx  in  its  mode 
of  ossification,  though  an  epiphysis  is  not  infrequently 
seen  at  the  head  of  the  bone  also. 
{B)  The  Lower  Extremity  : 
The  OS  innominatum : 

Three  main  primary  centres  for  ilium,  ischium,  and 
pubis,  appearing  respectively  in  the  second,  third,  and 
fourth  months  (i.u.l.).  The  three  parts  of  the  bone 
are  separated  at  first  by  the  Y-shaped  acetabular 
cartilage. 

Five  secondary  centres  appear  about  puberty  for  the 
crest,  symphysis  pubis,  anterior  inferior  iliac  spine, 
ischial  tuberosity,  and  the  acetabular  cartilage.  These 
unite  at  about  the  twenty-fifth  year. 
The  femur : 

I  centre  for  the  shaft  in  the  fifth  week  (i.u.l.). 

I  centre  for  the  lower  end  in  the  ninth  month  (i.u.l.) — 

union  with  shaft  in  the  twentieth  year. 
I  centre  for  the  head  in  the  first  year — union  with  shaft  in 

the  eighteenth  year. 
I  centre  for  the  great  trochanter  in  the  fourth  year. 
I  centre  for  the  small  trochanter  in  the  fourteenth  year. 
The  patella  : 

I  centre  in  the  third  year. 


APPENDIX  gi 

The  tibia  and  fibula  : 

I   centre  for  the  shaft  of  the  tibia  in  the  seventh  week 
(i.u.l.). 

I  centre  for  the  shaft  of  the  fibula  in  the  eighth  week 
(i.u.l.)- 

J  centre  for  the  upper  end  of  the  tibia  in  the  first  year- 
union  at  twenty. 

I  centre  for  the  upper  end  of  the  fibula  in  the  fourth  year 
— union  at  twenty-five. 

1  centre  for  the  lower  end  of  the  tibia  in  the  second  year 
— union  at  eighteen. 

I  centre  for  the  lower  end  of  the  fibula  in  the  second 
year — union  at  twenty. 
The  tarsus  : 

The  OS  calcis,  astragalus  and  cuboid  alone  have  centres 
of  ossification  at  birth,  these  appearing  respectively  in 
the  sixth,  seventh,  and  ninth  months.  The  os  calcis 
possesses  a  secondary  centre,  appearing  about  the 
tenth  year,  for  its  posterior  surface. 
The  metatarsus  and  phalanges  : 

Centres  appear  as  in  metacarpus,  etc. 


INDEX 


Abdominal  aorta,  6i 

plaues,  50 

regions,  51 
Acromial  spine  and  process,  19,  20 
Acromio-clavicular  joint,  19 
Adductor  magnus  tendon,  75 

tubercle,  75 
Anal  canal,  length  of,  87 
"  Anatomical  snufF-box,"  27,  28, 29 
Ankle  region,  76 
Antecubital  space,  24 
Anterior  annular ligament(ankle), 

7S 
Anterior  annular  ligament  (wrist), 

25,  26 
Anterior  crural  nerve,  83 

tibial  artery,  81 

tibial  nerve,  84 

triangle  of  neck,  12 
Antrum  of  Highmore,  11 
Aortic  arch,  38 

intercostals,  40 

valve,  37 
Apex  beat,  36 
Apices  of  lung,  45 
Appendix,  57 

length  of,  86 
Ascending  aorta,  38 

colon,  57 

length  of,  86 
Astragalus,  77 
Auricular  area,  37 
Auriculo-temporal  nerve,  15 
Axilla,  21 
Axillary  artery,  20,  29 

lymphatics,  22 

Base  of  brain,  4 
Basic  fossae,  8 
Basilic  vein,  24 
Biceps  femoris,  74 

humeri,  21,  24 
Bicipital  fascia,  24 

groove,  21 

sulci,  24 
Bile-duct,  64 

length  of,  86 
Bony  points  of  elbow,  23 
Brachial  artery,  24,  29 

plexus,  17 


Bregma,  2 
Broca's  area,  6 
Bronchi,  46 

length  of,  86 
Bryant's  line  and  triangle,  71 
Bulb  of  penis,  67 

of  vestibule,  67 

Caecum,  56 

length  of,  86 
Canal  of  epididymis,  87 
Cardiac  orifice,  54 
Carotid  arteries,  13 

triangle,  13 

tubercle,  13 
Central  point,  50 

tendinous  point  of  perineum, 
67,68 
Cephalic  vein,  24,  25 
Cerebellum,  5 
Cerebrum,  4 

Cervical  sympathetic,  16 
Circumflex  nerve  and  artery,  30 
Clavicle,  19 
Clitoris,  68 
Coeliac  axis,  61 
Colles's  fascia,  67 
Common  bile-duct,  64,  65 

carotid  artery,  38 

femoral  artery,  81 

iliac  artery,  62 
Conus  meduUaris,  66 
Coraco-brachialis  fold,  22,  29 
Coracoid  process,  20 
Coronal  suture,  2 
Coronary  artery,  61 
Creases  of  palm  and  fingers,  33 

of  wrist,  25 
Cricoid  cartilage,  18,  47 
Crura  of  penis,  67 
Crural  canal,  73 

length  of,  87 
Cuboid  bone,  76 
Cuneiform  bone,  26 
Curvatures  of  stomach,  56 

Deep  cardiac  dulness,  45 
epigastric  artery,  62 
palmar  arch,  30 
plantar  arch,  82 


92 


INDEX 


93 


Deltoid,  20 
Descending  aorta,  38 

colon,  58 

length  of,  87 
Diaphragm,  64 
Digital  arteries,  30 
Dorsalis  pedis  artery,  82 
Douglas's  fold,  43,  53 

pouch,  68 
Duodeno-jejunal  fold,  55 
Duodenum,  55 

length  of,  86 
Dura  mater,  59,  66 

Elbow  region,  23 

Epiglottis,  18 

Epiphyses,  89 

Epiphj'sial  line  of  humerus,  21,  23 
of  femur,  75 

Epitrochlear  gland,  25 

Extensor  tendons  of  foot,  64 
of  wrist,  28 

External  abdominal  ring,  54 
angular  frontal  process,  3 
annular  ligament  (foot),  80 
carotid  arter}',  10 
iliac  artery,  62 
jugular  vein,  15 
lateral  ligament  (knee),  74 
parieto-occipital  fissure,  6 
plantar  artery  and  nerve,  82, 

84 
popliteal  nerve,  74,  84 
saphenous   vein    and    nerve, 
82.83 

Facial  artery,  14 

nerve,  9,  10 
Fallopian  tubes,  length  of,  87 
False  ribs,  34 
Falx  cerebri,  2 

Female  urethra,  length  of,  87 
Femoral  canal  and  ring,  73 
Fibula,  74 

Filum  terminale,  66 
First  costal  cartilage  and  rib,  34 
First  interspace,  34 
p-issures  of  lung,  44 
Flexor  carpi  radialis,  25,  29 
ulnaris,  25 

sublimis,  25,  26 

synovial  sheaths,  26,  27 
Floating  ribs,  34 
Fontanelle,  anterior,  2 

posterior,  2 
p-QOt  region,  76 
Foramen  of  Winslow,  64 
Fornices  of  vagina,  68 
Frontal  sinus,  11 

Gall-bladder,  64 
Gastro-hepatic  omentum,  64 


Genital  area,  67 
Gluteal  arter}-,  60 
Gluteus  maximus,  70 
Gracilis,  75 
Great  auricular  nerve,  17 

occipital  nerve,  14 

sciatic  nerve,  83 

Hamilton's  test,  20 
Hand  region,  25 
Heart,  35 
Hepatic  artery,  61,  64,  65 

flexure,  57 
Hesselbach's  triangle,  62 
Hip  region,  70,  71 
Houston's  valves,  68 
Humerus,  head  of,  20,  22 
Hunter's  canal,  73 

Ileo-c£ecal  valve,  56 
Iliac  colon,  58 

length  of,  87 

crest,  52 

spines,  52,  53 

tubercles,  53 
Ilio-pelvic  colon,  58 
length  of,  87 
Ilio-tibial  band,  75 
Inferior  dental  nerve  and  artery, 
10 

mesenteric  artery,  62 

temporal  crest,  3,  4 

vena  cava,  40,  62 
Infraclavicular  space,  20 
Infra-orbital  foramen,  11 
Inguinal  canal,  54 

length  of,  87 

groove,  71 
Inion,  I 
Innominate  artery,  38 

veins,  39,  40 
Intercostal  space,  35 
Internal  abdominal  ring,  54 

annular  ligament  (foot),  79 

carotid  artery,  13 

jugular  vein,  16 

mammary  arterj',  39 

plantar  artery  and  nerve,  82, 
84 

popliteal  nerve,  84 

pudic  artery,  81 

saphenous  nerve,  83 
vein,  83 
Intertubercular  plane,  50,  53 
Ischial  spine,  81 

tuberosity,  70 
Ischio-rectal  fossa.',  68 
Island  of  Rtil,  5 

Kidney,  59 

length  and  weight  of,  87 
8—2 


94 


INDEX 


Knee  region,  74 
Knuckles,  33 

Labia  majora  and  minora,  67 

Lachrymal  sac,  10 

Lambda,  2 

Lambdoid  suture,  2 

Larjmx,  18 

Lateral  sinus,  2,  4,  5,  9 

ventricles,  8 

vertical  plane,  49 
Length  of  femur  and  tibia,  74 

of  humerus,  21 
Ligamentum  patellae,  75 

teres,  63 
Lines  semilunares,  52 

transversae,  52 
Lingual  artery,  14 
Liver,  63 

weight  of,  88 
Ludv^fig's  angle,  35 

plane,  51 
Lumbar  puncture,  66 
Lungs,  42 

weight  of,  88 

Macewen's  triangle,  4,  8 
Malar  tubercle,  3 
Mamma,  34 
Masseter  muscle,  9 
Mastoid  antrum,  8 
McBurney's  point,  57 
Median  nerve,  24,  32 

vertical  plane,  49 
Mental  foramen,  1 1 
Mesentery  of  small  intestine,  56 
Mesial  fissure  of  brain,  i 
Metacarpo-phalangeal  joint,  33 
Metopic  suture,  2 
Middle  cerebral  artery,  5 

meningeal  artery,  6,  7 
Mid-tarsal  joint,  78 
Mitral  valve,  37 
Mons  veneris,  67 
Morris's  quadrilateral,  60 
Muscular  triangle,  12 
Musculo-cutaneous  nerve  (arm),  3 1 

(leg),  85 
Musculo-phrenic  artery,  39 
Musculo-spiral  nerve,  24,  31 

Nasal  duct,  10 

Nasion,  i 

Natal  fold,  71 

Nelaton's  line,  71 

Ninth  costal  cartilage,  35,  50,  59 

Nipple,  35 

Obelion,  2 
Occipital  artery,  14 
nerve  (great),  14 
(small),  17 


CEsophagus,  47 
Olecranon,  23 
Omo-hyoid  muscle,  13 
Orbit,  boundaries  of,  i  o 
Os  calcis,  77 
Os  uteri,  68 
Ovary,  61,  87,  88 

Palmar  fascia,  33 
Palmaris  longiis,  32 
Pancreas.  56 

weight  of,  88 
Paracentesis  of  pericardium,  46 
Paracentral  point,  50 
Parietal  eminence,  2 
Parieto-occipital  sulcus,  6 
Parotid  gland,  9 
Pectoralis  major  and  fold,  21 

minor,  29 
Pelvic  colon,  58 

length  of,  87 
Pericardium,  46 
Perineum,  67 
Peroneal  nerve,  74,  84 

tendons,  76,  80 

tubercle,  76,  80 
Petit' s  triangle,  54 
Pharynx,  1 1 

length  of,  86 
Phrenic  nerve,  16 
Pisiform  bone,  25,  26 
Plantar  arch,  82 
Pleura,  41 
Popliteal  artery,  81 

space,  74 
Portal  vein,  64 

Posterior       annular       ligament 
(wrist;,  28 

auricular  artery  and  nerve,  14 

inferior  iliac  spine,  81 

interosseous  nerve,  24.  32 

superior  iliac  spine,  53 

tibial  artery  I  and  nerve,  82,  84 

triangle,  13 
Poupart's  ligament,  71 
Prepatellar  bursa,  76 
Prostate  gland,  53 

weight  of,  88 
Pubic  spine,  53 
Pudic  vessels,  67 
Pulmonary  artery,  39 

valve,  37 
Pylorus,  55 
Pyriforrais  muscle,  80 

Radial  artery,  25,  28,  29 

nerve,  24,  31 

tubercle,  28 
Radius,  23 

Receptaculum  chj-li,  47,  87 
Rectal  area,  67,  68 

examination,  69 


INDEX 


95 


Rectum,  58 

length  of,  87 
Reid's  base  line,  5 
Renal  artery,  62 
Rima  glottidis,  18 
Rolandic  area,  6 

fissure,  6 
Roots  of  lung,  45 

Sagittal  suture,  2 
Saphenous  opening,  73 
Sartorius,  75 
Scalenus  anticus,  15 
Scaphoid  bone  (carpus),  25 

(tarsus),  77,  78 
Scarpa's  triangle,  72 
Sciatic  artery,  So 
nerve  (great),  83 

(small),  84 
Semilunar  fold  of  Douglas,  52 
Semimembranosus,  75 
Seminiferous  tubules,  length  of, 

87 
Semitendinosus.  75 
Shoulder  region,  19 
Sinuses  of  nose,  12 
Small  intestine,  56 

occipital  nerve,  17 

sciatic  nerve,  84 
Sphenoidal  sinus,  12 
Spinal  accessory  nerve,  16 

cord,  65 

length   and    weight,    86, 
88 
Spinous  plane,  52 
Spleen,  65 
Splenic  artery,  61 

flexure,  57 
Stenson's  duct,  9 
Sterno-mastoid,  12 
Sterno-xiphoid  plane,  52 
Stomach,  54 
Styloid    process    of    radius    and 

ulna,  27 
Subclavian  artery,  15,  39 

triangle,  13 
Subcostal  plane.  52 
Submaxillary  gland  and  triangle, 

12 
Subpubic  angle,  67 
Superficial  cardiac  dulness,  45 

cervical  plexus,  17 

femoral  artery,  81 

lymphatics  of  arm,  22 
of  leg,  72 

palmar  arch,  30 

temporal  artery,  15 
Superior  epigastric  artery,  39 

longitudinal  sinus,  2 

mediastinum,  39 

mesenteric  artery,  61 

temporal  ciest,  3,  6 


Superior  thyroid  artery,  13 

vena  cava,  40 
Supra-acromial  nerve,  17 
Supraclavicular  nerve,  17 
Suprameatal  crest  and  spine,  3,  8 

fossa,  8 
Supra-orlDital  foramen,  11 
Suprarenals,  weight  of,  88 
Suprasternal  nerve,  17 

plane,  52 
Sustentaculum  tali,  77 
Sylvian  fissure,  5 

point,  5 
Sympathetic  chain  and  ganglia, 

16 
Symphysis  pubis,  53 
Synovial  membrane  of  knee,  76 

sheaths  of  ankle,  78,  79 
of  wrist  (extensor),  28 
(flexor),  26 

Tegmen  antri,  9 
Temporo-spheuoidal  sulcus,  6 
Tendo  Achillis,  78 

oculi,  10 
Tendons  of  ankle  region,  76 

of  wrist,  25 
Tentorium  cerebelli,  5 
Testis,  length  and  weight,  87,  88 
Theca  vertebralis,  66 
Thoracic  aorta,  38 

duct,  47 

plane,  50 
Thyroid  isthmus,  18 
Tibial  tuberosities,  74 
Tibialis  anticus,  77 

posticus,  77 
Tonsil,  10 
Trachea,  18 

Transpyloric  plane,  50,  55 
Transverse  cervical  nerve,  17 

colon,  57,  86 

creases  of  palm,  33 
of  wrist,  25 

facial  arter}',  9 
Transversus  perinei,  67 

process  of  atlas,  16 
Trapezium,  25 
Triangles  of  neck,  12 
Triangular  ligament,  67 
Tricuspid  valve,  38 
Trochanter  of  femur,  70 
True  riVjs,  34 
Tuberosities  of  humerus,  20 

of  tibia,  74 

Ulnar  artery,  24,  30 

nerve,  32 
Umbilical  plane,  52 
Umbilicus,  52 
Unciform  bone,  26 
Urachus,  61 


96 


INDEX 


Ureter,  60,  87 
Urethra,  male,  87 

female,  87 
Uterus,  dimensions  of,  87 

Vagina,  examination  of  68 

dimensions  of,  87 
Vagus  nerve,  16 
Valves  of  heart,  37 
Veins  of  elbow,  24 


Vena  azygos  major,  40 
Ventricular  area,  36 
Vermiform  appendix,  57 
Vestibule,  68 
Vocal  cords,  18 

Wrist -joint,  25 
Wrist  region,  25 

Zygomatic  process,  3 


H.    K.    LEWIS,    136,    GOWER   STREET,    LONDON,    W.C. 


jmi 

mn 

'^M^^^^[^^^l^st^m^ 

s^^m^mmK 

COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

1 

DATE  DUE 

i 

1 

1       C2a( 10- 53) lOOM 

Rawling 


QM551 

R19 

1915 


Landmarks  and  surface  markings 
of  the  human  bod./'. 


HHifHHH' 


£Bi^saj«r^St^r-iritr:rt> 


iSSffiMffliiiiffiBiSP^gSii^l^^i^niK 


